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DAVID B. REATH, M.D.
Notice of Privacy Practices for Protected Health Information
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
PLEASE REVIEW IT CAREFULLY!
Our office is permitted by federal privacy laws to make uses and disclosures of your health
information for purposes of treatment, payment, and health care operations. Protected health
information is the information we create and obtain in providing our services to you. Such
information may include documenting your symptoms, examination and test results, diagnoses,
treatment, and applying for future care or treatment. It also includes billing documents for those
Examples of uses of your health information for treatment purposes are:
® A nurse obtains treatment information about you and records it in a health record.
® During the course of your treatment, the physician determines he/she will need to consult with
another specialist in the area. He/she will share the information with such specialist and obtain
Examples of use of your health information for payment purposes:
® We submit requests for payment to your health insurance company. The health insurance
company or business associate helping us obtain payment requests information from us
regarding your medical care given. We will provide information to them about you and the care
Example of use of your health information for Health Care Operations:
¨ We may obtain services from business associates such as quality assessment, quality
improvement, outcome evaluation, protocol and clinical guidelines development, training
programs, credentialing, medical review, legal services, and insurance. We will share
information about you with such business associates as necessary to obtain these services.
1Your Health Information Rights
The health and billing records we maintain are the physical property of the doctor’s
office. You have the following rights with respect to your Protected Health
1. Request a restriction on certain uses and disclosures of your health information by
delivering the request in writing to our office—we are not required to grant the request
but we will comply with any request granted;
2. Obtain a paper copy of the Notice of Privacy Practices for Protected Health
Information (Notice”) by making a request at our office;
3. Right to inspect and copy your health record and billing record—you may exercise this
right by delivering the request in writing to our office using the form we provide to you
upon request; appeal a denial of access to your protected health information except in
4. Right to request that your health care record be amended to correct or incomplete or
incorrect information by delivering a written request to our office using the form we
provide to you upon request. (The physician or other health care provider is not
required to make such amendments); you may file a statement of disagreement if your
amendment is denied, and require that he request for amendment and any denial be
attached in all future disclosures of your protected health information;
5. Right to receive an accounting of disclosures of your health information as required to
be maintained by law by delivering a written request to our office using the form we
provide to you upon request. An accounting will not include internal uses of information
for treatment, payment, or operations, disclosures made to you or made at your
request, or disclosures made to family members or friends in the course of providing
6. Right to confidential communication by requesting that communication of your health
information be made by alternative means or at an alternative location by delivering the
request in writing to our office using the form we give you upon request;
If you want to exercise any of these above rights, please contact: Theresa Wyatt, Patient
Care Coordinator (865) 450-9253. She will provide you with assistance on the steps to
take to exercise your rights.
The office is required to:
® Maintain the privacy of your health information as required by law;
2® Provide you with a notice as to our duties and privacy practices as to the information we
collect and maintain about you;
® Abide by the terms of this Notice;
®Notify you if we cannot accommodate a requested restriction of request; and
® Accommodate your reasonable requests regarding methods to communicate health
information with you.
® Accommodate your request for an accounting of disclosures.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and
access practices and to enact new provisions regarding the protected health information we
maintain. If our information practices change, we will amend our Notice. You are entitled to
receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by
visiting our office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding
the handling of your information, you may contact: Theresa Wyatt, Patient Care Coordinator
Additionally, if you believe your privacy rights have been violated, you may file a written
complaint at our office by delivering the written complaint to: Theresa Wyatt, Patient Care
Coordinator. You may also file a complaint by mailing it to the Secretary of Health and Human
Services in Washington, D.C.
® We cannot, and will not, require you to waive the right to file a complaint with the Secretary
of Health and Human Services (HHS) as a condition of receiving treatment from the office.
®We cannot, and will not, retaliate against you for filing a complaint with the Secretary of
Health and Human Services.
3Following is a List of Other Uses and Disclosures Allowed by the Privacy Rule
We may contact you to provide you with appointment reminders, with information about
treatment alternatives, or with information about other health-related benefits and services that
may be of interest to you. We may contact you as a part of a fund raising effort.
Notification—Opportunity to Agree or Object
Unless you object we may use or disclose your protected health information to notify, or assist
in notifying a family member, personal representative, or other person responsible for your care,
about your location, and about your general condition, or your death.
Communication with Family- Using our best judgment, we may disclose to a family member,
other relative, close personal friend, or any other person you identify, health information relevant
to that person’s involvement in your care or in payment for such care if you do not object or in
We may use and disclose your protected health information to assist in disaster relief efforts.
Opportunity to Agree of Object Not Required
PUBLIC HEALTH ACTIVITIES
Controlling Disease – As required by law, we may disclose your protected health information
to public health or legal authorities charged with preventing or controlling disease, injury or
Child Abuse & Neglect – We may disclose protected health information to public authorities
as allowed by law to report child abuse or neglect.
Food and Drug Administration (FDA) – We may disclose to the FDA your protected health
information relating to adverse events with respect to food, supplements, products and product
defects, or post-marketing surveillance information to enable product recalls, repairs, or
VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE
We can disclose protected health information to governmental authorities to the extent the
disclosure is authorized by stature or regulation and in the exercise or professional judgment the
doctor believes the disclosure is necessary to prevent serious harm to the individual or other
Federal law allows us to release your protected health information to appropriate health
oversight agencies or for health oversight activities to include audits, civil, administrative or
criminal investigations: inspections; licensures or disciplinary actions, and for similar reasons
related to the administration of healthcare.
We may disclose your protected health information in the course of any judicial or administrative
proceeding as allowed or required by law, or as directed by a proper court order or
administrative tribunal, provided that only the protected health information released is expressly
authorized by such order, or in response to a subpoena, discovery request or other lawful
We may disclose your protected health information for law enforcement purposes as required
by law, such as when required by court order, including laws that require reporting of certain
types of wounds or other physical injury.
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
We may disclose your protected health information to funeral directors or coroners consistent
with applicable law to allow them to carry out their duties.
ORGAN PROCUREMENT ORGANIZATIONS
Consistent with applicable law, we may disclose your protected health information to organ
procurement organizations or other entities engaged in the procurement, banking, or
transplantation of organs, eyes, or tissue for the purpose of donation and transplant.
We may disclose information to researchers when their research has been approved by an
institutional review board that has reviewed the research proposal and established protocols to
ensure the privacy of your protected health information.
THREAT TO HEALTH AND SAFETY
To avert a serious threat to health or safety, we may disclose your protected health information
consistent with applicable law to prevent or lessen a serious, imminent threat to the health or
safety of a person or to the public.
5FOR SPECIALIZED GOVERNMENTAL FUNCTIONS
We may disclose your protected health information for specialized government functions as
authorized by law such as to Armed Forces personnel, for national security purposes, or to
public assistance program personnel.
If you are an inmate of a correctional institution, we may disclose to the institution or it’s agents
the protected health information necessary for your health and the health and sagely of other
If you are seeking compensation through Workers Compensation, we may disclose your
protected health information to the extent necessary to comply with laws relating to Workers
Other uses and Disclosures
¨ Other uses and disclosures besides those identified in this Notice will be made only as
otherwise authorized by law or with your written authorization which you may revoke except to
the extent information or action has already been taken.
¨ We maintain a website that provides information about our entity, this Notice is also
posted on that website (www.dbreath.com).
Effective Date: 4/14/2003