THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW CAN GET ACCESS TO THIS INFORMATION. PLEASE READ THIS NOTICE CAREFULLY.
At Manhattan’s Physician Group, we believe that your health information is personal. We maintain records of the care
and services that you receive at our medical offices, and we are committed to keeping such records private.
We are required by federal and applicable state law to protect the privacy of individually identifiable health information
(“Protected Health Information”). When we use and/or disclose your Protected Health Information, we are required to
abide by the terms of this Notice, which describes the privacy practices of Manhattan’s Physician Group and its affiliated
medical offices. This Notice applies to all of the health records that identify you and the care you receive at Manhattan’s
Physician’s Group medical offices. If you are under 18 years of age, your parents or guardian must sign for you and
handle your privacy rights for you.
MANHATTAN’S PHYSICIAN GROUP
All of our employees and medical offices follow the terms of this Notice. These medical offices and their locations are
shown at the end of this Notice.
HOW MANHATTAN’S PHYSICIAN GROUP MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
When you become a patient of Manhattan’s Physician Group, we may use and disclose your Protected Health
Information within Manhattan’s Physician Group and disclose your health information outside Manhattan’s Physician
Group for the reasons described in this Notice. The following categories describe some of the ways that we will use
and disclose your Protected Health Information:
Treatment. We may use your Protected Health Information to provide you with health care services. We may disclose
your Protected Health Information to doctors, nurses, technicians, medical or nursing students, or other persons at
Manhattan’s Physician Group who need that information to take care of you. For example, a doctor treating you for a
broken leg may need to ask another doctor if you have diabetes because diabetes may slow the leg’s healing process.
This may involve talking to doctors and others not employed by us. We also may disclose your Protected Health
Information to people outside Manhattan’s Physician Group who may be involved in your health care, such as treating
doctors, home care providers, pharmacies, drug or medical device experts, and family members.
Payment. We may use and disclose your Protected Health Information so that the health care you receive may be billed
and paid for by you, your insurance company, or another third party. For example, we may give information about a
procedure you had to your health plan so it will pay us or reimburse you for the procedure. We may also tell your health
plan about a treatment you are going to receive so we can get prior payment approval or learn if your plan will pay for
the treatment.
Health Care Operations. We may use and disclose your Protected Health Information for our health care operations.
These uses and disclosures help Manhattan’s Physician Group maintain and improve patient care. For example, we may
use your health information to review the care you received and to evaluate the performance of our staff in caring for
you. We also may combine Protected Health Information about many patients to identify new services to offer, what
services are not needed, and whether certain therapies are effective. We may also disclose information to doctors,
nurses, technicians, medical students, and other persons at Manhattan’s Physician Group for learning and quality
improvement purposes, accreditation, certification, licensing or credentialing activities; or for the purpose of health
care fraud and abuse detection or compliance.
Contacting You. We may use and disclose health information to reach you about appointments and other matters.
We may contact you by mail, telephone, or email. We may leave voice messages at the telephone number you provide
us with, and we may respond to your email address.
Health-Related Services. We may use and disclose health information about you to send you mailings about healthrelated
products and services available at Manhattan’s Physician Group.
Legal Matters. We will disclose health information about you outside Manhattan’s Physician Group when required to do
so by federal, state, or local law, or in the course of a judicial or administrative proceeding in response to a legal order
or other lawful process. We may disclose health information about you for public health reasons, like reporting births,
deaths, child abuse or neglect, reactions to medications or problems with medical products.
We may release health information to help control the spread of disease or to notify a person whose health
may be threatened. We may disclose health information to a health oversight agency for activities authorized
such as for audits, investigations, inspections, and licensure.
Workers’ Compensation. We may disclose your Protected Health Information as necessary to comply with
compensation laws.
AUTHORIZATIONS FOR OTHER USES AND DISCLOSURES
As described above, we will use your health information and disclose it outside Manhattan’s Physician Group
treatment, payment, health care operations, and when permitted or required by law. We will not use or disclose
health information for other reasons without your written authorization. For example, you may want us to release
medical information to your employer or to your child’s school. These kinds of uses and disclosures of your
information will be made only with your written authorization. Except to the extent that we have already taken
in reliance upon your authorization, you may revoke your authorization at any time by delivering a written revocation
statement to one of our privacy officers (each a “Practice Administrator”) at the appropriate address identified below.
YOUR RIGHTS REGARDING HEALTH INFORMATION
Right to Accounting. You may request an accounting, which is a listing of the entities or persons (other than
yourself) to whom Manhattan’s Physician Group has disclosed your Protected Health Information without your
authorization. The accounting would not include disclosures for treatment, payment, health care operations,
other disclosures exempted by law. Your request for an accounting of disclosures must be in writing, signed,
It must identify the time period of the disclosures and the Manhattan’s Physician Group medical office that maintains
records about which you want the accounting. We will not list disclosures made before April 14, 2003, or those
earlier than 6 years before your request. Your request should indicate the form in which you want the list (for
on paper or electronically). You must submit your written request to the Practice Administrator of the Manhattan’s
Physician Group medical office that maintains the records. We will respond to you within 60 days. We will give
first listing within any 12-month period free, but we will charge you for all other accountings requested within
12 months.
Right to Amend. If you feel that Protected Health Information we have about you is incorrect or incomplete,
have the right to ask us to amend your medical records. Your request for an amendment must be in writing,
and dated. It must specify the records you wish to amend, identify the Manhattan’s Physician Group medical
that maintains those records, and give the reason for your request. You must address your request to the Practice
Administrator of the Manhattan’s Physician Group medical office that maintains the records you wish to amend.
Manhattan’s Physician Group will respond to you within 60 days. We may deny your request; if we do, we will
why and explain your options.
Right to Inspect and Obtain Copy. You have the right to inspect and obtain a copy of your completed health
Your request to inspect or obtain a copy of the records must be submitted in writing, signed, and dated, to
Administrator of the Manhattan’s Physician Group medical office that maintains the records. We may charge
processing your request. IfUnder limited circumstances, Manhattan’s Physician Group may deny you access
of your records. If we deny your request to inspect or obtain a copy of the records, you may appeal the denial
Manhattan’s Physician Group.
Right to Request Restrictions. You have the right to ask us to restrict the uses or disclosures we make of your
Protected Health Information for treatment, payment, or health care operations. While we will consider all requests
additional restrictions carefully, we are not required to agree to all requested restrictions. A request for a restriction
must be signed and dated, and you must identify the Manhattan’s Physician Group medical office that maintains
information. The request should also describe the information you want restricted, indicate whether you want
the use or the disclosure of the information or both, and tell us who should not receive the restricted information.
must submit your request in writing to the Practice Administrator of the Manhattan’s Physician Group medical
maintains the information you want restricted. We will tell you if we agree with your request or not. If we do
will comply with your request unless the information is needed to provide you with emergency treatment.
Personal Representatives. You may exercise your rights through a personal representative who will be required by
Manhattan’s Physician Group to produce evidence of his or her authority to act on your behalf. Proof of authority
may be made by a notarized power of attorney, a court order of appointment of the person as your legal guardian or
conservator, or if you are the parent of a minor child. Manhattan’s Physician Group reserves the right to deny access to
your personal representative.
Right to Receive a Paper Copy of this Notice. If you received this Notice electronically or from our website, you have
the right to request this Notice in paper form.
Right to Request Confidential Communications. You have the right to request that we communicate with you about
your health in a certain way or at a certain location. For example, you can ask that we only contact you at work or
by mail. Your request for confidential communications must be in writing, signed, and dated. It must identify the
Manhattan’s Physician Group medical office making the confidential communications and specify how or where you
wish to be contacted. You need not tell us the reason for your request, and we will not ask. You must send your written
request to the Practice Administrator and to the medical records department of the Manhattan’s Physician Group medical
office making the confidential communications. We will accommodate all reasonable requests.
COMPLAINTS
If you believe your privacy rights have been violated or you disagree with a decision that Manhattan’s Physician Group
made about your Protected Health Information, you may file a written complaint with Manhattan’s Physician Group’s
Practice Administrator at the medical office that you believe violated your privacy rights. You may also file a complaint
with the Secretary of the U.S. Department of Health and Human Services. Upon request, the Practice Administrator will
provide you with the address of the Secretary. Manhattan’s Physician Group will not retaliate against you if you file a
complaint with the Practice Administrator or with the Secretary.
CHANGES TO THIS NOTICE
Manhattan’s Physician Group may change this Notice at any time. Any change in the Notice could apply to medical
information we already have about you, as well as any information we receive in the future. We will post a copy of the
current Notice at each of our medical offices and on our Web site, www.mpgcares.com.
EFFECTIVE DATE
This Notice is effective on July 10, 2006.
LIMITATION ON APPLICATION OF NOTICE
This Notice does not apply to information that does not identify an individual with respect to which there is no
reasonable basis to believe that the information can be used to identify the individual.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, YOU MAY TELEPHONE THE NUMBER SHOWN HERE FOR YOUR
MANHATTAN’S PHYSICIAN GROUP MEDICAL OFFICE AND ASK FOR THE PRACTICE ADMINISTRATOR.
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