Privacy

NOTICE OF PRIVACY PRACTICES

Effective Date: 4/14/03

OUR PLEDGE REGARDING MEDICAL INFORMATION:

We understand that medical information about you and your health is personal, and we are committed to
protecting medical information about you. We are required by law to make sure that medical information that
identifies you is kept private. This notice will tell you about the ways in which we may use and disclose
medical information about you. It is our legal duty to comply with this notice and provide you a copy of our
Notice of Privacy Practices.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATON ABOUT YOU.

  • For Treatment
  • For Payment
  • For Health Care Operations
  • Appointment Reminders
  • Treatment Alternatives
  • Health-Related Benefits & Services
  • Research
  • As Required by Law
  • Defense of Medical Professional Liability Claims
  • Individuals Involved in Your Care Or Payment of Your Care
  • To Avert a Serious Threat to Health or Safety

SPECIAL SITUATIONS APPLY TO THE FOLLOWING:

  • Organ and Tissue Donation, Military and Veterans, Worker’s Compensation
  • Public Health Risks, Health Oversight Activities
  • Lawsuits and Disputes, Law Enforcement
  • Coroners, Medical Examiners and Funeral Directors
  • National Security and Intelligence Activities
  • Protective Services for the President and Others
  • Inmates

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

  • Right to Inspect & Copy
  • Right to Amend
  • Right to Accounting Disclosures
  • Right to Request Restrictions
  • Right to Request Confidential Communications
  • Right to a Paper Copy of this Notice

COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint with our practice or with the
Secretary of the Department of Health and Human Services. To file a complaint with your practice, contact
West Georgia Urology Associates Privacy Office, 150 Clinic Ave., Suite 202, Carrollton, GA 30117. All
complaints must be submitted in writing. You will not be penalized for filing a complaint.

WHO WILL FOLLOW THIS NOTICE:

  • Any health-care professional authorized to enter information into your medical chart, and all physicians
  • covering for our practice.
  • All employees, staff and other personnel.
  • All departments and units of West Georgia Urology Associates, P.C.