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   Notice of Privacy Practices

Fort Wayne Psychiatry PC, 2414 E. State Blvd. # 301, Fort Wayne , IN 46805 Tel. 260-484-1312



We are required by law to keep your medical information private, give you this notice describing our legal duty, privacy practices and your rights regarding your medical information and follow the terms of the notice that is now in effect. If you have any questions about this Notice, please contact our privacy officer, Prevesh Rustagi, MD at above address.

We have a right to change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law, make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep including information previously created or received before the changes. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

Use and disclosure of your medical information: the following section describes different ways that we use and disclose medical information. Not every use or disclosure would be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We would not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us.

For treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, physician assistant students, office staff or other people who are taking care of you or other healthcare providers to whom you are referred for treatment.

For payment: We may use and disclose your medical information to get paid for the services we provide to you.

For healthcare operations: We may use and disclose your medical information for our healthcare operations. This may include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.

For business associates: We may share your medical information with a third party "business associate " that performs various activities (e.g. billing, collection, electronic medical records, transcription). Whenever an arrangement between us and a business associate involves the use or disclosure of your medical information, we will have a written contract that contains terms that will protect the privacy of your medical information.

Additional uses and disclosures with opportunity to object: In addition to above, we may use and disclose medical information for the following purposes. You have the opportunity to object. If you are not present or able to object, then we may, using professional judgment, determine whether the disclosure is in your best interest.

For promotion: We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. You may contact us to request that these materials not be sent to you.

Facility directories: Unless you object, we may disclose the location at which you are receiving care, your condition (in general terms), and your religious affiliation. All this information, except religious affiliation, will be disclosed to the people that ask for you by name. Members of the clergy will be told your religious affiliation.

Others involved in your health care: Unless you object, we may disclose to a member of your family, a relative, a close friend, a personal representative or any other person you identify, your medical information that directly relates to that person's involvement in your health care. We will also use our professional judgment to make decisions in your best interest about allowing someone to pickup medicine, medical supplies, x-ray or medical information about you.

Emergencies: In an emergency treatment situation, we will provide you with a Notice Of Privacy Practices as soon as reasonably practicable after the delivery of treatment.

Communication barriers: We may use and disclose your protected health information if we have attempted to obtain acknowledgment from you of our Notice Of Privacy Practices but have been unable to do so due to substantial communication barriers and we determine, using professional judgment, that you would agree.

Additional uses and disclosures without opportunity to object : We may use or disclose your medical information in the following situations without your authorization or opportunity to object.

Public health: for public health purposes to a public health authority or a person who is at risk of contracting or spreading your disease.

Health oversight: to help the oversight agency for activities authorized by law, such as audits, investigations, and inspections.

Abuse or neglect: to an appropriate authority to report possible child abuse or neglect, domestic violence or abuse or neglect of a dependent adult.

Food and drug administration: as required by the FDA to track products.

Legal proceedings: in the course of legal proceedings, under certain circumstances

To prevent suicide or significant self-harm.

Law enforcement: for law enforcement purposes, such as pertaining to victims of a crime or to prevent a crime.

Coroners, Funeral Directors, and Organ Donation: for the Coroner, Medical Examiner or Funeral Director to perform duties authorized by law and for organ donation purposes.

Research: to researchers when their research has been approved by an Institutional

Review Board or Privacy Board.

Soldiers, inmates and national security: to military supervisors of armed forces personnel or to custodians of inmates, as necessary. Preserving national security may also necessitate disclosure of protected health information.

Worker's Compensation: to comply with workers' compensation laws.

Compliance: to the Department of Health and Human Services to investigate our compliance.

In general, we may use or disclose your protected health information as required by law and limited to the relevant requirements of the law.

Your Rights: you have the right to:

Inspect and copy your protected health information: In most cases you have the right to look at or get a copy of health information about you. We will charge you photocopy fees as allowed by law. However, we may refuse to provide access to certain psychotherapy notes or information for a civil or criminal proceeding.

Request a restriction of your protected health information: You may ask us not to use or disclose certain parts of your protected health information for treatment, payment or healthcare operations. You may also request that information not be disclosed to family members or friends who may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, but if we do agree, then we must act accordingly except in case of an emergency.

Request to receive confidential communications from us by alternative means or at an alternative location: We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specifications of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request.

Ask us to amend your protected health information: You may request an amendment of protected health information about you. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and your medical record will note the disputed information.

Receive an accounting of certain disclosures we may have made: This right applies to disclosures for purposes other than treatment, payment or healthcare operations. It excludes disclosures we have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures. The right to receive this information is subject to certain exceptions, restrictions and limitations.

Obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

Complaints: If you are concerned that we have violated your privacy rights or you disagree with a decision we made about access to your records, you may contact the person listed above. You may also send a written complaint to the US Department of Health and Human Services. Our Privacy Officer listed above can provide you with the appropriate address upon request.

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