Your Information. Your Rights. My Responsibilities.
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.
When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.
Get An Electronic Or Paper Copy Of Your Medical Record: You can ask to see or get an electronic or paper copy of your medical record and other health information Dr. Lieberman has about you. Ask Dr. Lieberman how to do this. Dr. Lieberman will provide a copy or a summary of your health information. She may charge a reasonable, cost- based fee.
Ask to Have Your Record Corrected: You can ask Dr. Lieberman to correct health information about you that you think is incorrect or incomplete. Ask Dr. Lieberman how to do this. She may say “no” to your request, but she will tell you why in writing within 60 days.
Request Confidential Communications: You can ask Dr. Lieberman to contact you in a specific way (for example, home or office phone) or to send mail to a different address. She will say “yes” to all reasonable requests.
Ask To Limit Shared Information: You can ask Dr. Lieberman not to use or share certain health information for treatment, payment, or operations. She is not required to agree to your request, and she may say “no” if it would affect your care. If you pay for a service or health care item out-of pocket in full, you can ask Dr. Lieberman not to share that information for the purpose of payment or operations with your health insurer. Dr. Lieberman will say “yes” unless a law requires her to share that information.
Get a List of Those With Whom Information Has Been Shared: You can ask for a list (accounting) of the times your information has been shared for six years prior to the date you ask, who it has been shared with, and why. Dr. Lieberman will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked her to make). Dr. Lieberman will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get A Copy Of This Notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. Dr. Lieberman will provide you with a paper copy promptly.
Choose Someone To Act For You: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. Dr. Lieberman will make sure the person has this authority and can act for you before she takes any action.
File A Complaint: You can complain if you feel Dr. Lieberman has violated your rights by contacting her at 703-827- 1900. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. Dr. Lieberman will not retaliate against you for filing a complaint.
For certain health information, you can tell Dr. Lieberman your choices about what she shares. If you have a clear preference for how she shares your information in the situations described below, talk to her. Tell Dr. Lieberman what you want her to do, and she will follow your instructions. In these cases, you have both the right and choice to tell Dr. Lieberman to:
Share information with your family, close friends, or others involved in your care.
Share information in a disaster relief situation.
Include your information in a hospital directory.
If you are not able to tell Dr. Lieberman your preference, for example if you are unconscious, Dr. Lieberman may go ahead and share your information if she believes it is in your best interest. She may also share your information when needed to lessen a serious and imminent threat to health or safety.
USES AND DISCLOSURES
Dr. Lieberman typically uses or shares your health information in the following ways:
To Treat You: Dr. Lieberman can use your health information and share it with other professionals who are treating you. Example: Dr. Lieberman talks to your physician to coordinate treatment
To Run Her Organization: Dr. Lieberman can use and share your health information to run her practice, improve your care, and contact you when necessary. Example: Dr. Lieberman can use health information about you to manage your treatment and services.
Bill You For Services: Dr. Lieberman can use and share your health information to bill and get payment from health plans or other entities. Example: Dr. Lieberman gives information about you to your health insurance plan so it will reimburse you for your services.
Minors: If you are a minor (under 18 years of age), Dr. Lieberman may be compelled to release certain types of information to your parents or guardian in accordance with applicable law.
Dr. Lieberman is allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. Dr. Lieberman has to meet many conditions in the law before she can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consum ers/index.html
Dr. Lieberman can share health information about you for certain situations such as:
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Dr. Lieberman will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that she is complying with federal privacy law.
Dr. Lieberman can share health information about you in response to a court or administrative order, or in response to a subpoena.
Dr. Lieberman can share your information to address workers’ compensation, law enforcement, and other government requests, including:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Dr. Lieberman can share health information with a coroner, medical examiner, or funeral director when an individual dies.
In the following cases, Dr. Lieberman will never share your information unless you give written permission: marketing purposes, sale of your information, most sharing of psychotherapy notes, research, and fundraising.
Dr. Lieberman is required by law to maintain the privacy and security of your protected health information.
Dr. Lieberman will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
Dr. Lieberman must follow the duties and privacy practices described in this notice and give you a copy of it.
Dr. Lieberman will not use or share your information other than as described here unless you tell her she can in writing. If you tell her she can, you may change your mind at any time. Let Dr. Lieberman know in writing if you change your mind.
For more information, see:
Dr. Lieberman can change the terms of this notice, and the changes will apply to all information she has about you. The new notice will be available upon request, in Dr. Lieberman’s office, and on her website.