KNEIBERT CLINIC L.L.C.
NOTICE OF PRIVACY PRACTICES
Effective Date - April 14, 2003
I . This notice describes how medical information
about you may be used and disclosed as well as how you
access to the information. Please review it carefully.
II. Our Duty to Safeguard Your Protected Health Information.
Individually identifiable information about your past,
present, or future health or condition, the provision of
health care to you, or payment for the health care is considered “Protected
Health Information” (“PHI”). We are required
to extend certain protections to your PHI, and to give
you this Notice about our privacy practices that explains
how, when and why we may use or disclose your PHI. Except
in specified circumstances, we must use or disclose only
the minimum necessary PHI to accomplish the purpose of
use or disclosure.
We are required to follow the privacy practices described
in this Notice, though we reserve the right to change our
privacy practices and the terms of this Notice at any time.
If we do so, we will post a new Notice in our Business
Office. You may request a copy of the new notice from the
Business Office, and it will also be posted on our website
III. How We May Use and Disclose Your Protected Health
We use and disclose PHI for a variety of reasons. For
most uses/disclosures, we must obtain your consent. For
we must have your written authorization. However, the law
provides that we are permitted to use and disclose your
For treatment: We may disclose your PHI to doctors, nurses
and other health care personnel who are involved in providing
your health care.
To obtain payment: We may use/disclose your PHI in order
to bill and to collect payment for your health care services.
For healthcare operations: We may use or disclose, as-needed,
your protected health information in order to support the
business activities of our practice. These activities include,
but are not limited to, quality assessment activities,
employee review activities, training of medical students,
licensing, and conducting or arranging for other business
activities. For example, we may disclose your PHI to medical
school students that see patients at our office. We may
also call you by name in the waiting room when your physician
is ready to see you. We may use or disclose your protected
health information, as necessary, to contact you to remind
you of your appointment.
Subject to certain rules, we may use or disclose your
health data without your prior permission for other reasons
for public health issues, to report abuse or neglect, as
part of research studies, to arrange funerals and organ
donation, for workers’ compensation claims, and in
When required to by law, we also may disclose health
care data. In certain cases, we must respond to requests
law enforcement officials or valid court orders.
Other Permitted and Required Uses and Disclosures will
be made only with your consent, authorization or opportunity
to object unless required by law.
You may revoke this authorization, at any time, in writing,
except to the extent that your physician or the physician’s
practice has taken an action in reliance on the use or
disclosure indicated in the authorization.
IV. Your Rights
Following is a statement of your rights with respect
to your PHI.
You have the right to inspect and copy your PHI. If
you request copies, we will charge you a fee for
the cost of
copying, mailing and related supplies. Under federal
law, however, you may not inspect or copy the following
psychotherapy notes; information compiled in reasonable
anticipation of, or use in, a civil, criminal, or administrative
action or proceeding, and protected PHI that is subject
to law that prohibits access to PHI.
You have the right to request a restriction on your
PHI. This means you may ask us not to use or disclose
part of your PHI for the purposes of treatment,
payment or health care operations. You may also request that any part
of your PHI not be disclosed to family members or friends
who may be involved in your
care or for notification purposes as described in this Notice of Privacy
Practices. Your request must state the specific restriction
requested and to whom you
want the restriction to apply.
Your physician is not required to agree to a restriction
that you may request. If physician believes it is in your
best interest to permit
use and disclosure
of your PHI, your PHI will not be restricted. You then have the right
to use another healthcare professional.
You have the right to request that your health data
be given to you in a private manner. You may ask us to send
mail to an address other
tell us in writing about certain way or place we can use to inform
You have the right to request that your physician
amend your PHI. If we deny your request for amendment, you have
the right to file
with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal.
You have the right to receive an accounting of disclosures
we have made of your PHI except for treatment, payment,
gave written permission.
We reserve the right to change the terms of this notice
and will inform you by mail or any changes. You then have
the right to
object or withdraw
provided in this notice.
V. Questions and Complaints
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Kneibert Clinic L.L.C.
Robert E. Christian
686 Lester Street
Poplar Bluff, MO 63901
Telephone (573) 686-2411
If you think that we may have violated your privacy rights,
contact person named above. You may also submit a written
the U.S. Department
of Health and Human Services. We will provide you with
the address to file your complaint with the U.S.
will not retaliate in any way if you choose to file a complaint.