Georgia Perinatal Consultants
Notice of Privacy Practices
Effective Date: 9/28/2022

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU (AS A PATIENT OF
THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO
YOUR HEALTH INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY

IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Raymond J. Allen, MD, 5780 Peachtree Dunwoody Road, Suite 380, Atlanta, GA 30342
404-303-7647

OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of health information that individually identifies you
(“Protected Health Information” or “PHI”). In conducting our business, we will create records regarding
you and the treatment and services we provide to you. We are required by law to maintain the confidentiality
of PHI and to notify affected individuals should a breach of unsecured PHI occur. We also are required by
law to provide you with this notice of our legal duties and the privacy practices that we maintain in our
practice concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy
practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important
information:

  • How we may use and disclose your PHI
  • Your privacy rights in your PHI
  • Our obligations concerning the use and disclosure of your PHI

The terms of this notice apply to all records containing your PHI that are created or retained by our
practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or
amendment to this notice will be effective for all of your records that our practice has created or
maintained in the past, and for any of your records that we may create or maintain in the future.
Our practice will post a copy of our current Notice on our website and in our offices in a visible
location at all times, and you may request a copy of our most current Notice at any time.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
The following categories describe the typical ways in which we may use and disclose your PHI.
Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory
tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. Many of the
people who work for our practice – including, but not limited to our doctors, sonographers and nurses –
may use or disclose your PHI in order to treat you or to assist others in your treatment. We may also disclose
your PHI to other health care providers outside our practice such as pharmacists, doctors, nurses and
technicians for purposes related to your treatment.

Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services
and items you may receive from us. For example, we may contact your health insurer to certify that you are
eligible for benefits, and we may provide your insurer with details regarding your treatment to determine if
your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain
payment from third parties that may be responsible for such costs, such as family members. Also, we may
use your PHI to bill you directly for services and items.

Health Care Operations. Our practice may use and disclose your PHI to operate our business. As examples
of the ways in which we may use and disclose your information for our operations, our practice may use
your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business
planning activities for our practice. We may disclose your PHI to other health care providers that have a
relationship with you (for example your health plan) and entities to assist in their health care operations.
Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind you of
an appointment.

Treatment Options. Our practice may use and disclose your PHI to inform you of potential treatment
options or alternatives.

Health-Related Benefits and Services. Our practice may use and disclose your PHI to inform you of
health-related benefits or services that may be of interest to you.
For certain health information, you can tell us your choices about what we share. If you have a clear
preference for how we share your information in the situations described below, talk to us. Tell us what
you want us to do, and we will follow your instructions.

  • Release of Information to Family/Friends. Our practice may release your PHI to a friend or
    family member that is involved in your care, or who assists in taking care of you. We may also
    notify your family about your location or general condition or disclose such information for an
    entity assisting in a disaster relief effort. If you are not able to tell us your preference, for example
    if you are unconscious, we may go ahead and share your information if we believe it is in your best
    interest. We may also share your information when needed to lessen a serious and imminent threat
    to health or safety.
  • Fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you
    again.

USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES
We are allowed or required to share your PHI in certain unique scenarios – usually in ways that contribute
to the public good, such as public health and research. We have to meet many conditions in the law before
we can share your information for these purposes. For more information see:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

The following categories describe unique scenarios in which we may use or disclose your PHI.

Disclosures Requested By Law. Our practice will use and disclose your PHI when we are required to do
so by international, federal, state or local law.
Public Health Risks. Our practice may disclose PHI to help with certain public health and safety issues,
such as:

  • Disclosing to public health authorities authorized by law to collect or receive information for
    purposes of preventing or controlling disease, injury or disability, such as maintaining vital records
    like births and deaths, or conducting public health surveillance, public health investigations, and
    public health interventions
  • Reporting child abuse or neglect
  • Notifying a person regarding potential exposure to a communicable disease
  • Notifying a person regarding a potential risk for spreading or contracting a disease or condition
  • Reporting reactions to drugs or problems with products or devices
  • Notifying individuals if a product or device they may be using has been recalled
  • Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or
    neglect of an adult patient (including domestic violence); however, we will only disclose this
    information if the patient agrees or we are required or authorized by law to disclose this information
  • Notifying your employer under limited circumstances related primarily to workplace injury or
    illness or medical surveillance

Health Oversight Activities. Our practice may disclose your PHI to a health oversight agency for activities
authorized by law. Oversight activities can include, for example, investigations, inspections, audits,
surveys, licensure and disciplinary actions; civil administrative, and criminal procedures or actions; or other
activities necessary for the government to monitor government programs, compliance with civil rights laws
and health care system in general.

Lawsuits and Similar Proceedings. Our practice may use and disclose your PHI in response to a court or
administrative order. We also may disclose your PHI in response to a discovery request, subpoena, or other
lawful process by another party involved in the dispute, but only if we have received assurances of an effort
to inform you of the request or to obtain an order protecting the information the party has requested.
Law Enforcement. We may release PHI to a law enforcement official:

  • Regarding a crime victim in certain situations
  • Concerning a death we believe has result from criminal conduct
  • Regarding criminal conduct at our offices
  • In response to a warrant, summons, court order, subpoena or similar legal process
  • To identify/locate a suspect, material witness, fugitives or missing person
  • In an emergency, to report a crime (including the location or victim(s) of the crime, or the
    description, identify or location of the perpetrator)

Deceased Patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased
individual or to identify the cause of death. If necessary, we also may release information in order for
funeral directors to perform their jobs.

Organ and Tissue Donation. Our practice may release your PHI to organizations that handle organ, eye
or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ
or tissue donation and transplantation if you are an organ donor.

Research. Our practice may use and disclose your PHI for research purposes in certain limited
circumstances.

Serious Threats to Health or Safety. Our practice may use and disclose your PHI when necessary to
reduce or prevent a serious threat to the health and safety of you, another individual, or the public. Under
these circumstances, we will only make disclosures to a person or organization we believe in good faith is
able to help prevent or lessen the threat.

Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces
(including veterans) and if deemed necessary by the appropriate authorities.

National Security. Our practice may disclose your PHI to federal official for intelligence and national
security activities authorized by law. We also may disclose PHI to federal officials in order to protect the
President, other officials or foreign heads of state, or to conduct investigations.

Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if
you are an inmate or under the custody of a law enforcement official for permitted purposes such as: (a) for
the institution to provide health care services to you, (b) for the safety and security of the institution, and/or
(c) to protect your health and safety or the health and safety of other individuals.
Workers’ Compensation. Our practice may release your PHI for workers’ compensation and similar
programs.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights regarding the PHI that we maintain about you. For more information about
these rights, you may contact Raymond J. Allen, MD, 404-303-7647; written requests related to these
rights must be submitted to Raymond J. Allen, MD, 5780 Peachtree Dunwoody Road, Suite 380,
Atlanta, GA 30342.

Confidential Communications. You have the right to request that our practice communicate with you
about your health related issues in a particular manner or at a certain location. For instance, you may ask
that we contact you at home, rather than work. In order to request a type of confidential communication,
you must make a written request to our address above, specifying the requested method of contact, or the
location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not
need to give a reason for your request.

Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI
for treatment, payment or health care operations. Additionally, you have the right to request that we restrict
our disclosure of your PHI to only certain individual(s) involved in your care or the payment of your care,
such as family members and friends. We are not required to agree to your request; however, if we do
agree, we are bound by our agreement except when otherwise required or permitted by law, such as in
emergencies to treat you. If you pay for a service or health care item out-of-pocket in full, you can ask us
not to share that information for the purpose of payment or our operations with your health insurer. We will
say “yes” unless a law requires us to share that information. In order to request a restriction on our use or
disclosure of your PHI, you must make your request in writing to our address above. Your request must
describe in a clear and concise fashion:

(a) The information you wish restricted
(b) Whether you are requesting to limit our practice’s use, disclosure or both; and
(c) To whom you want the limits to apply

Inspection and Copies. You have the rights to inspect and obtain a copy of the PHI that may be used to
make decisions about your care, including patient medical records and billing records, with limited
exceptions such as psychotherapy notes. You must submit your request in writing to our address above in
order to inspect and/or obtain a copy of your PHI. Our practice may deny your request to inspect and/or
copy in certain limited circumstances; however, you may request a review of our denial. Another licensed
health care professional chosen by us will conduct reviews. When we agree to your request, we will provide
a copy or a summary of your health information, usually within 30 days of your request. We may charge a
reasonable, cost-based fee.

Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete,
and you may request an amendment for as long as the information is kept by or for our practice. To request
an amendment, your request must be made in writing and submitted to our address above. You must provide
us with a reason that supports your request for an amendment. Our practice will deny your request if you
fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your
request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of
the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and
copy; or (d) not created by our practice, unless the individual or entity that created the information is not
available to amend the information.

Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An
“accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI
for non-treatment, non-payment or non-operations purposes. Use of your PHI as part of the routine patient
care in our practice is not required to be documented. For example, the doctor sharing information with the
nurse; or the billing department using your information to file your insurance claim with the nurse; or the
billing department using your information to file your insurance claim. In order to obtain an accounting of
disclosures, you must submit your request in writing to our address above. All requests for an “accounting
of disclosures” must state a time period, which may not be longer than six (6) years prior to the date of your
request. The first list you request within a 12-month period is free of charge, but our practice may charge
you for additional list(s) within the same 12-month period. Our practice will notify you of the costs involved
with additional requests, and you may withdraw you request before you incur any costs.

Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy
practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this
notice, contact Raymond J. Allen, MD 404-303-7647.

Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint
with our practice or with the Secretary of the Department of Health and Human Services, Office for Civil
Rights (“OCR”). You may file a complaint with our practice by submitting your complaint in writing to
our address above. You may file a complaint with OCR by sending a letter to 200 Independence Avenue,
S.W., Washington, D.C. 20201, calling 1-877-696-6775, or at www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.

Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written
authorization for uses and disclosures that are not identified by this notice or permitted by applicable law,
such as for marketing purposes, sale of PHI, and most sharing of psychotherapy notes. Any authorization
you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing,
except to the extent we have already relied on it. After you revoke your authorization, we will no longer
use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain
records of your care.
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If you have any questions regarding this notice or our health information privacy policies, please
contact Raymond J. Allen, MD, 404-303-7647.