Notice of Privacy Practices

 
 
 

Forouz Jowkar PA-C, Ph.D
2019 Galisteo St., Bldg 10, Ste D
Santa Fe NM 87505
Phone: (505) 424 9172
Email: healthylivingsantafe@gmail.com


The privacy of your health information is important. Please review this notice carefully.

In compliance with the Health Insurance Portability and Accountability Act (HIPPA) and Health and Human Services Regulations – effective April 21, 2003 – this notice describes how medical information about you may be used, how it may be disclosed, and how you may get access to this information.

  • Medical information about you is collected and stored as needed for treatment in the form of a personal history, treatment plan, treatment plan reviews, and progress notes on each session. This information is considered Protected Health Information or PHI. If you pay by insurance or other third party, I am often required to report your current diagnosis and progress in treatment. This report is either made by postal mail, fax or electronic mail. You are entitled to know the specific information your insurance company or other third party requires, and may request a copy of it at any time.

  • Disclosure of your PHI will only be made with your prior written authorization and consent. Please note these exceptions:

  • According to New Mexico state law, I am required to disclose your PHI in the event you are a danger to yourself or others or if you are involved in or report to me the abuse or neglect of a child or elderly person.

  • I may be required to disclose your PHI for reasons of national security.

  • I may be required to disclose your PHI if I receive a subpoena.

  • You may revoke your authorization, in writing, at any time.

Your Rights With Regard to Your Personal Health Information:

  • You have the right to request restrictions on certain uses and disclosures of your PHI. Your request will be honored whenever possible. Any denial of your request will be discussed with you.

  • You have the right to amend your PHI.

  • You have the right to receive an accounting of disclosures of your PHI when it is released for reasons other than treatment, payment and healthcare operations.

  • You have the right to receive a paper copy of this notice.

  • If you have any complaint with how your PHI has been handled, or if you believe your privacy rights have been violated, you may speak directly with me, or you may file a complaint with the Secretary of the U.S. Department of Health and Human Services. Your care will not be limited and action will not be taken against you if you file a complaint.

My Legal Duties:

  • I am required by law to protect the privacy of your individually identifiable health information, and to provide you with this notice.

  • I am required to abide by the terms of this notice.

  • In the event that my privacy practices or duties change, I am required to advise you of any changes in writing.