This notice describes how medical information about you may be used and disclosed and how you have access to this information. Please review it carefully. If you have any questions about this notice, please contact our office at 480-456-6561.

This notice describes the privacy practices at our office.

We are required by law to:

Maintain the privacy of protected health information

Give you this notice of our legal duties and privacy practices regarding your health information

Follow the terms of the notice currently in effect

How we may use and disclose your health information

Described as follows are the ways we may use and disclose your health information. Except for the following purposes we will use and disclose your health information only with your written permission. You may revoke such permission at any time by writing to our Privacy Officer or Compliance Officer.

Treatment – We may use and disclose your health information for your treatment and to provide you with treatment-related health care services. For example, we may disclose your health information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

Payment – We may use and disclose your health information so that others or we may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received. For example, we may give information to your health plan so that they will pay for your treatment.

Health Care Operations – We may use and disclose your health information to evaluate and improve our medical care and to operate and manage our office. For example, we may use and disclose information to a peer review organization or a health plan that is evaluating our care. We may also share information with others that have a relationship with you for their health care operation activities such as appointment reminders, treatment alternatives, and health-related benefits and services. When appropriate, we may share your health information with a person involved in, or paying for your care (such as a family member or significant other). We may notify your family about your location or condition or disclose such information to an entity assisting in disaster relief.

Research – We may disclose your health information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another for the same condition. Before we do so, the project needs to go through a special approval process. Even without special approval, we may permit researchers to look at records to help identify patients who may be included in their research as long as they do not remove or copy any of your health information.

As Required by Law – We will disclose your health information when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety – We may use and disclose your health information when necessary to prevent a serious threat to the health and safety of you, another person, or the public. Disclosures will be made only to someone who can prevent the threat.

Business Associates – We may disclose your health information to our business associates that perform functions on our behalf or provide us with services if necessary. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose the information for any other purpose than appears in their contract with us.

Military and Veterans – If you are a member of the Armed Forces, we may release your health information as required by military command authorities. If you are a member of a foreign military we may release your health information to the foreign military command authority.

Workers’ Compensation – We may release your health information for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.

Public Health Risks – We may disclose your health information for public health activities to prevent or control disease, injury or disability. We may use your health information in reporting births or deaths, suspected child abuse or neglect, medication reactions or product malfunctions or injuries, and product recall notifications. We may use your health information to notify someone who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. If we are concerned that a patient may have been a victim of abuse, neglect or domestic violence we may ask your permission to make a disclosure to an appropriate government authority. We will make that disclosure only when you agree or when required or authorized to do so by law.

Health Oversight Activities – We may disclose your health information to an agency who oversees health activities for activities authorized by law. These may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes – If you are involved in a lawsuit or dispute, we may disclose your health information in response to a court or administrative order. We may disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement – We may release your health information at the request of a law enforcement official if 1) there is a court order, subpoena, warrant, summons or similar process; 2) if the request is limited to information needed to identify or locate a suspect, fugitive, material witness, or missing person; 3) the information is about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain your agreement; 4) the information is about a death that may be the result of criminal conduct; 5) the information is relevant to criminal conduct on our premises; and 6) it is needed in an emergency to report a crime, the location of a crime or victims, or the identity, description, or location of the person who may have committed the crime.

Coroners, Medical Examiners, and Funeral Directors – We may release your health information to a coroner, medical examiner, or funeral director to identify a deceased person or cause of death, or other similar circumstance.

National Security and Intelligence Activities – We may disclose your health information to authorized federal officials for intelligence and other national security activities authorized by law.

Inmates or Individuals in Custody – If you are an inmate of a correctional institution or in custody we may disclose your information 1) for the institution to provide you with health care; 2) to protect your health and safety or that of others; and 3) for the safety and security of the institution.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Right to Inspect and Copy – You have the right to inspect and copy your medical and billing records by written request to our Privacy Officer or Compliance Officer.

Right to Amend – You have the right to request an amendment to your records by written request to our office. If Dr. Pace believes the record is correct, you still have the right to have your disagreement noted in your file.

Right to an Accounting of Disclosures – You have the right to an accounting of certain disclosures by written request to our office.

Right to Request Restrictions – You have the right to request restriction or limitation on your health information used for treatment, payment or health care operations. You may request us to limit disclosure to someone involved in your care or in payment for your care (such as a spouse) by written request to our office. We are not required to agree with your request, but we will try to comply.

Right to Request Confidential Communication – You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. You can ask, for example, that we contact you only by mail or at work. Your written request must specify how or where you wish to be contacted and be addressed to our office. We will accommodate reasonable requests.

Right to File a Complaint – You have the right to file a complaint if you believe your information was used or shared in a way that is not allowed under the privacy law, or if you were not able to exercise your rights. You can file a complaint with our office or your health insurer. You may also file a complaint with the U.S. Government.

CHANGES TO THIS NOTICE

We may change this notice and make it effective for medical information we already have on file as well as new information. The current notice will be available at all times. You have the right to request a paper copy of the current notice at any visit or by written request to our office at:

Dr. Carolyn B. Pace

Southern Avenue Medical Center

2034 E Southern Avenue, Suite P

Tempe, Arizona 85282