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Effective Date of Policy: 3/27/2007

Protected health information (PHI) will only be released from our practice with a properly executed authorization form from the patient or his/her representative, except for treatment, payment, or health care operations (TPO) and as otherwise required by law. Examples of some instances in which we are required to disclose your PHI include:

Public health activities – Information regarding victims of abuse, neglect or domestic violence – Health oversight activities – Judicial and administrative proceedings – Law enforcement purposes – Organ doner purposes – Research purposes under certain circumstances – National security and intelligence – Correctional institutions – Worker’s Compensation

Nevaeh, LLC will ony use or discluse PHI, except as noted above, consistent with the terms of the authorization.

A patient may revoke his/her authorization to use or disclose PHI at any time, but actions taken prior to the revocation are excluded. If authorization is a condition of obtaining insurance coverage, and the authorization is revoked, the insurer may contest a claim under the policy.

Authorizations must be property executed by the patient or his/her personal representative. It should include the date signed, specific PHI to be released or used, to whom this use or release relates, and an expiration date for authorization.

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