HIPAA Notice for sharing of medical Information
See My Baby Live and SMB Sonography
Effective Date: 05/14/2024
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY
OUR PLEDGE REGARDING HEALTH INFORMATION:
We understand that health information about you and your care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal technologist or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.
We are required by law to:
Make sure that health information that identifies you is kept private;
Give you this notice of our legal duties and privacy practices with respect to health information about you; and
Follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment. We may use health information about you to provide you with healthcare treatment or services. We may disclose health information about you to doctors, nurses, technologists, or other personnel who are involved in taking care of you. They may work at our offices, they may work at offices that are affiliated with ours, or another doctor’s office who has referred you to us.
For Payment. We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collect from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations. We may use and disclose health information about you for operations of our health care practice. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, etc.
As Required by Law. We will disclose health information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to prevent the threat.
Military and Veterans. If you are a member of the armed forces or separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.
Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose health information about you for public health activities. These activities generally include the following:
To prevent or control disease, injury, or disability;
To report births and deaths;
To report child abuse or neglect;
To report reactions to medications or problems with products;
To notify people of recalls of products they may be using;
To notify person or organization required to receive information on FDA-regulated products;
To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree OR when required or authorized by law.
Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, and inspections. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or obtain an order protecting the information requested.
Law Enforcement. We may release health information if asked to do so by a law enforcement official:
In reporting certain injuries as required by law;
In response to a court order, subpoena, warrant, summons or similar process;
To identify or locate a suspect, fugitive, material witness, or missing person;
About a victim of a crime if the victim agrees to disclosure or under certain limited circumstances, we are unable to obtain the person’s agreement;
About criminal conduct at our facility; and
In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.
National Security and Intelligence Activities. We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others. We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with healthcare; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU:
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care.
*To inspect and copy health information, you must submit your request in writing to MJ Saunders, Owner, See My Baby Live DBA SMB Sonography. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services associated with your request.
Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as we keep the information. To request an amendment, your request must be made in writing, submitted to MJ Saunders, Owner, See My Baby Live DBA SMB Sonography, and must be contained on one page of paper legibly handwritten or typed. In addition, you must provide a reason that supports your request for an amendment.
*We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you as us to amend information that:
Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the health information kept by or for our practice;
Is not part of the information which you would be permitted to inspect or copy; or
Is accurate and complete.
Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.
Right to an Accounting of Disclosures. You have the right to request a list of accounting for any disclosures of your health information that we have made, except for uses and disclosures for treatment, payment, and health care operations as previously described.
*To request this list of disclosures, you must submit your request in writing to MJ Saunders, Owner, See My Baby Live DBA SMB Sonography. Your request must state a time period which may not be longer than six years and may not include date prior to May 09, 2023. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in you care or the payment of your care, such as a family member or friend. For example, you could ask that we restrict a specified technologist from use of your information, or that we not disclose information to your spouse about a procedure you had.
We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request a restriction, you must make your request in writing to MJ Saunders, Owner, See My Baby Live DBA SMB Sonography In your request, you must tell us what information you want to limit and to whom you want the limits to apply; for example, use of any information by a specified technologist, or disclosure of specified procedure to your spouse.
Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box.
*To request confidential communications, you must make your request in writing to MJ Saunders, Owner, See My Baby Live DBA SMB Sonography We will not ask you the reason for your request. We will accommodate most reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of this Notice. You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from MJ Saunders, Owner, See My Baby Live DBA SMB Sonography.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health 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 in our facility. The notice will contain on the first page, the effective date. In addition, each time you register for health care services, we will offer you a copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with us or with the appropriate government agency. To file a complaint with us, contact MJ Saunders, Owner, See My Baby Live DBA SMB Sonography. All complaints must be submitted in writing. You will NOT be penalized for filing a complaint.
OTHER USES OF HEALTH INFORMATION:
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to uses or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered in your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
Acknowledgement of Receipt of this Notice
We will request that you sign a separate form or notice acknowledging you have received a copy of this notice. If you choose, or are not able to sign, a staff member will sign their name and date. This acknowledgement will be filed with your records.
This contract may be signed electronically or in hard copy. If signed in hard copy, it will be kept with the business as a valid record and a copy can be provided to the signee if requested. Electronic signatures count as original for all purposes. By writing/signing your name below, both parties agree to the terms and provisions of this agreement.
Recipient name ______________________________________________________

Recipient signature ____________________________________________________

Recipient date signed _______________________________________________