ACCUCARE MEDICAL GROUP

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get assets to this information. AccuCare Medical Group is required by law to protect your health information for privacy and confidentiality. Please read it carefully.

We may disclosure health information regarding:

Treatment – to other healthcare professionals within our practice.

Payment – to insurance companies regarding payment of healthcare operations.

Workers Compensation – to comply with State Workers’ Compensation Laws.

Emergencies – to notify or assist your family – responsible person in case of injury or death.

Public Health – to public authorities for purposes of preventing – controlling disease, child – abuse, reactions to medicine, and reporting disease or infection, for example.

Judicial and Administration Proceedings

Law Enforcement – to identify a fugitive, material witnesses were missing person, subpoenas.

Deceased Persons – to coroners or medical examiners.

Organ Donations – to organizations that procure, bank, or transplant organs and tissues.

Public Safety – to persons preventing imminent threat to the public’s health or safety.

Specialized Government Agencies – to military, national security, prisoner and Gov. Benefits purposes

Change of Ownership of this practice – to mergers are new owners.

Your Health Information Rights – you may review your health info, request restrictions and disclosures, have alternative communication methods of your information, can amend your health information, receive full accounting of health info, and have a paper copy of this document after signature. AccuCare Medical Group can deny or not amend upon your request via a formal explanation.

Changes to this Notice of Privacy Practices – AccuCare Medical Group can amend this document. If you have questions regarding anything in this document you can contact the office manager at AccuCare Medical Group will take a personal appointment within two working days.

Complaints – address the Office Manager or make a personal appointment within two days.

I have read the Privacy Notice and understand my rights and authorize AccuCare Medical Group to use and discloser my protected health care information for treatment, payment, and healthcare operations as described above.

_____________________ _______________________ ____________

Patient’s Name (print) Patient’s Signature Date

A more thorough explanation is available in the lobby or from the staff. You have 48 hours to review it. If you understand and agree with both documents you need not reply.

HIPPA COMPLIANCE DOCUMENTS AccuCare Medical Group FORM 2003