1. This is a formal notification, as required by CMS (Centers for Medicare and Medicaid Services) concerning the privacy policy of this practice.  It is important that all patients and staff understand the importance of guarding patient information.

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  3. This practice has a legal obligation to maintain all medical records and information in the strictest of confidence as required by law.  What this means to the patient is that we must safeguard patient information.  This means we cannot release information to others without your written consent, including conversations, reminder calls, test results and other information that may be of a confidential nature.  Patient information about health care is identified as “PHI” or Protected Health Information.

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  5. Your protected health information (PHI) is an intricate part of your medical care, and can be used or disclosed with your written consent as follows:
    • For your treatment in this practice and other locations under the physician’s immediate care. This may include any referral for services such as lab, x-rays, other diagnostic testing or treatment related to your condition or medical care needs. This may also include conversations with other physicians.
    • For obtaining payment for treatment with your identified insurance or health coverage program.  This would include any documentation related to this process, which may include history forms, progress notes or operative notes.  This would include eligibility verification, prior authorization and claim submission.
    • For operations of this practice, such as enrolling with insurance programs, hospital privileges, accounting and compliance with federal and state laws and regulations.
    • Appointment reminders and health related benefit services only with your consent identified on the registration form
    • Disclosure to your family and friends concerning any related health care information with your consent on the registration form which can be modified at any time orally, followed by written consent.
    • Consent is not required for emergency care and treatment.  An emergency is identified as a medical condition that in the judgment of the physician or medical entity required immediate and full information for care on your behalf.
    • Certain disclosures can be made without your consent, and they are as follows:
    • Disclosure required by the government or law enforcement agencies.  Specific areas that require release include gun shot wounds, domestic violence, and victims of abuse or neglect.
    • Information used for public health purposes, medical examiners or related to a person’s death or for the health department for disease tracking.
    • Information used for health care oversight, such as a site review by an insurance program.
    • Information related to organ donation.
    • Information related to certain research procedures, the majority of this information is stripped of any personal data, and is normally generic (age, sex, diagnosis) in nature.
    • Information provided to avoid harm if there is a threat to patient or other safety.
    • Specific governmental functions.
    • Workers compensation review.


  6. Your rights with respect to your protected health information.
    • The right to request limits on the uses and disclosure at registration or any time during your care.
    • The right to choose how we send this information to you, including an alternate address.
    • The right to see and obtain copies of this information, but there may be copy and postage fees. 
    • The right to get a listing of who we have made disclosures to about your PHI.
    • The right to correct and update your file through an amendment process if appropriate.


  7. This practice reserves the right to modify or change this Privacy Statement and process at any time.  Revision to the Notice will be available upon request by contacting the office. The changes will be effective retroactively to the initial date of the Privacy Notice.  An updated Privacy Notice will be posted in the office within 60 days of the revision. 

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  9. If you have a concern or complaint about how your protected health information is being used, from this time forward you should first contact our office to see if we can resolve your concerns or you may contact the Office of Civil Rights or the Ohio Medicare Carrier, GBA Palmetto.
Contact the office manager and complete a complaint form for review and discussion.

Name Cheryl Updegraff
Address 805 Columbia Road, Suite 111, Westlake, OH 44145
Phone (440) 808-9469


If you are not satisfied with this response, you may report the practice to:

Office of Civil Rights
Regional Manager
Department of Health & Human Services
233 N. Michigan Avenue, Suite 240
Chicago, Illinois 60601
(312) 886-1807

Or the local Medicare Part B Intermediary

GBA Palmetto
Part B Operations – HIPAA Compliance Concern
PO Box 182957
Columbus, Ohio 43218


This privacy plan is a working draft, which became effective November 15, 2002.

Patient Signature on receipt of Privacy Notice


Patient unable to sign due to


Patient refused to sign – witness


(Copy maintained in chart)

©2017 ENTGroup of Cleveland  805 Columbia Road, Suite 111 Westlake, Ohio 44145 (440) 808-9469
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