NOTICE OF PRIVACY PRACTICES
We are legally
required to protect the privacy of information that identifies you or could be
used to identify you, and relates to your past, present or future physical or
mental health condition(s) or the provision of past, present, or future
healthcare services (including payment for those services). This information is
called “protected health information” or “PHI” for short.
We are legally
required to follow the privacy practices that are described in this Notice. We
reserve the right to change our privacy policies and the terms of this Notice at
any time. Before any important policy change goes into effect, we will change
We will post a copy of
this Notice in all our registration areas for public viewing. You may also
request a copy of this Notice at any time by contacting Jack Chang, M.D.,
P.C. at 978-937-9333.
USE AND DISCLOSURE OF
YOUR PHI BY JACK CHANG, M.D., P.C.
Jack Chang, M.D., P.C. may use or disclose your PHI to carry out its responsibilities as a healthcare provider. Jack Chang, M.D., P.C. may use or disclose your PHI without your written authorization for the following reasons:
Operations. “Healthcare operations” at Jack Chang, M.D., P.C. include
activities related to improving quality of care, staff training, medical
education, and business management.
Reminders, Information about Healthcare Related Benefits and Treatment
Alternatives. We may use and disclose medical information to contact you as
a reminder that you have an appointment for a treatment or medical care at
Jack Chang, M.D., P.C. or to inform you of treatment alternatives or other
healthcare services or benefits that we offer.
As Required By Law.
We will disclose PHI when required to do so by federal or state law, including
in response to a court or administrative order, subpoena, discovery request,
warrant, summons or other lawful process. Jack Chang, M.D., P.C. may also
disclose PHI to law enforcement personnel or similar persons to avoid a serious
threat to the health or safety of a person or the public.
In addition, Jack
Chang, M.D., P.C. may use your PHI without your written authorization under
the following circumstances:
situations when your authorization cannot be reasonably obtained, including for
disaster relief purposes;
• To business associates
(outside vendors or consultants that perform services on behalf of Jack
Chang, M.D., P.C. and are contractually required to appropriately safeguard
• To other healthcare
facilities where Jack Chang, M.D., P.C. physicians and healthcare
professionals have privileges or to physicians from other healthcare facilities
who see patients at Jack Chang, M.D., P.C.
• With your
agreement, to a family member, relative, close personal friend, or any other
person you identify;
• To facilitate organ
or tissue donation if you are an organ donor;
• In connection with
workers’ compensation claims;
• To report abuse,
neglect, or domestic violence as required by state of federal law;
• For public health
and health oversight activities, such as preventing or controlling disease or
• To coroners,
medical examiners, or funeral directors as necessary to carry out their duties.
Certain actions, such
as most uses of disclosures of psychotherapy notes, the use and disclosure of
PHI for marketing purposes, and disclosures that constitute a sale of PHI, will
be made only with your written permission (authorization). Other uses or
disclosures of PHI that are not covered by this Notice or applicable laws also
will be made only with your written permission.
special privacy protections for particularly sensitive conditions or illnesses
such as HIV/AIDS, mental health, and substance abuse. Jack Chang, M.D., P.C.
will disclose such information only in a manner that is consistent with these
You may revoke your
permission at any time by writing to Jack Chang, M.D., P.C. at the address below.
Once you revoke your permission, we will stop using or disclosing such
information for the reasons covered by your written authorization. However, we
cannot take back any disclosures made with your permission. We will retain our
records of the care provided to you as required by law.
YOUR RIGHTS REGARDING
Although your medical
information is the property of Jack Chang, M.D., P.C. you have certain
rights regarding your PHI, including the right to:
• Inspect and Copy. With
certain exceptions, you have the right to inspect or receive a copy of your
medical information or both. We may charge a fee for these services. We may deny
your request in certain limited circumstances. If you are denied access to your
medical information, you may request that the denial be reviewed. Another
licensed healthcare professional chosen by Jack Chang, M.D., P.C. will
review your request and our denial.
• Request an
Amendment. If you feel that medical information we have about you is
incorrect or incomplete, you may ask us to amend information that is kept by or
for Jack Chang, M.D., P.C. We may deny your request if you ask us to
amend information that (a) was not created by Jack Chang, M.D., P.C. (b)
is not part of the medical information kept by or for Jack Chang, M.D., P.C.;
(c) is not medical information you are permitted to inspect or copy; or (d)
is accurate and complete in the record.
• Request an
Accounting of Disclosures. You may request a list of the disclosures we have
made of PHI that were for purposes other than treatment, payment, healthcare
operations and certain other purposes, or disclosures made with your written
authorization within the last six (6) years. You may be charged a fee in
connection with this request.
• Restrict or Limit
Use or Disclosure. You may ask us to restrict or limit the use or disclosure of
your PHI, including the disclosure of information to someone who is involved in
your care or the payment for your care, like a family member or friend. Your
request must state: (1) what information you want to limit; (2) whether you want
to limit Jack Chang, M.D., P.C’s use, disclosure or both; and (3) to whom the
limits apply, for example, disclosures to your spouse. We are not required to
agree to your request, unless it relates to an item or service you paid for in
full and out of pocket. In this case, you may request that we not share health
information pertaining only to that product or service with your health plan for
the purposes of carrying out payment or healthcare operations and we will comply
with your request unless the information is needed to provide you emergency
treatment or except as required by law.
Communications. Generally, we will use the address, telephone number and, in
some cases, the email address you give us to contact you. You may ask us to
communicate with you about medical matters in a certain way or at a certain
location. For example, you can ask that we only contact you at work. We will
accommodate all reasonable requests. Your request must specify how or where you
wish to be contacted.
• Notification in the
Event of a Breach. Consistent with federal and state laws, we will notify
you in the event unsecured PHI is used or disclosed by an unauthorized
All requests must be
submitted in writing to the address below. Your request must be specific and be
signed by you or an authorized representative.
If you believe your
privacy rights have been violated, you may file a complaint by writing to the
address below or by calling the Jack Chang, M.D., P.C. at 978-937-9333.
You may also file a complaint in writing with the Secretary of the U.S.
Department of Health and Human Services in Washington, D.C. or through the
regional office at J.F.K. Federal Building – Room 1874, Boston, MA 02203. The complaint must be
filed within 180 days of the alleged violation. There will be no retaliation for
filing a complaint.
If you have questions,
would like to submit a written request, or need further assistance regarding
this policy, please contact Jack Chang, M.D., P.C. at: 706 Rogers Street,
Lowell, MA 01852, or 978-937-9333.
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