| NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. |
Uses and Disclosures
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for
the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results
of laboratory tests and procedures will be available in your medical record to all health professionals who may provide
treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of
coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For
example, your health plan may request and receive information on dates of service, the services provided, and the
medical condition being treated.
Health care operations. Your health information may be used as necessary to support the day-to-day activities and
management of Mount Laurel Family Physicians. For example, information on the services you received may be used
to support budgeting and financial reporting, and activities to evaluate and promote quality.
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for
the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results
of laboratory tests and procedures will be available in your medical record to all health professionals who may provide
treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of
coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For
example, your health plan may request and receive information on dates of service, the services provided, and the
medical condition being treated.
Health care operations. Your health information may be used as necessary to support the day-to-day activities and
management of Mount Laurel Family Physicians. For example, information on the services you received may be used
to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement. Your health information may be disclosed to law enforcement agencies, without your permission,
to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with
government mandated reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by law.
For example, we are required to report certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use of any
purpose other than those listed above requires your specific written authorization. If you change your mind after
authorizing a use of disclosure of your information you may submit a written revocation of the authorization. However,
your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before
you notified us of your decision.
Additional Uses of Information
Appointment reminders. Your health information will be used by our staff to confirm upcoming appointments.
Individual Rights
You have certain rights under the federal privacy standards. These include:
• the right to request restrictions on the use and disclosure of your protected health information
• the right to receive confidential communications concerning your medical condition and treatment
• the right to inspect and copy your protected health information
• the right to amend or submit corrections to your protected health information
• the right to receive an accounting of how and to whom your protected health information has been disclosed
• the right to receive a printed copy of this notice
Mount Laurel Family Physicians Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this notice
of privacy practices.
We also are required to abide by the privacy policies and practices that are outline in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our
policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for
these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices
will be applied to all protected health information that we maintain.
Requests to Inspect Protected Health Information
As permitted by federal regulation, we require that requests to inspect or copy protected health information be
submitted in writing. You may obtain a form to request access to your records by contacting Kathleen Curtis.
Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter
outlining your concerns to:
Kathleen Fisher
Mount Laurel Family Physicians
204 Ark Road, Suite 103
Mt. Laurel, NJ 08054
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a
letter describing the cause of your concern to the same address.
You will not be penalized or otherwise retaliated against for filing a complaint.
Contact Person
The name and address of the person you can contact for further information concerning our privacy practices is:
Kathleen Fisher
Mount Laurel Family Physicians
204 Ark Road, Suite 103
Mt. Laurel, NJ 08054
(856) 778-4756
Effective Date
This notice is effective on or after April 1, 2003.
to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with
government mandated reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by law.
For example, we are required to report certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use of any
purpose other than those listed above requires your specific written authorization. If you change your mind after
authorizing a use of disclosure of your information you may submit a written revocation of the authorization. However,
your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before
you notified us of your decision.
Additional Uses of Information
Appointment reminders. Your health information will be used by our staff to confirm upcoming appointments.
Individual Rights
You have certain rights under the federal privacy standards. These include:
• the right to request restrictions on the use and disclosure of your protected health information
• the right to receive confidential communications concerning your medical condition and treatment
• the right to inspect and copy your protected health information
• the right to amend or submit corrections to your protected health information
• the right to receive an accounting of how and to whom your protected health information has been disclosed
• the right to receive a printed copy of this notice
Mount Laurel Family Physicians Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this notice
of privacy practices.
We also are required to abide by the privacy policies and practices that are outline in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our
policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for
these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices
will be applied to all protected health information that we maintain.
Requests to Inspect Protected Health Information
As permitted by federal regulation, we require that requests to inspect or copy protected health information be
submitted in writing. You may obtain a form to request access to your records by contacting Kathleen Curtis.
Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter
outlining your concerns to:
Kathleen Fisher
Mount Laurel Family Physicians
204 Ark Road, Suite 103
Mt. Laurel, NJ 08054
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a
letter describing the cause of your concern to the same address.
You will not be penalized or otherwise retaliated against for filing a complaint.
Contact Person
The name and address of the person you can contact for further information concerning our privacy practices is:
Kathleen Fisher
Mount Laurel Family Physicians
204 Ark Road, Suite 103
Mt. Laurel, NJ 08054
(856) 778-4756
Effective Date
This notice is effective on or after April 1, 2003.
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