Privacy Policy

---

**HIPAA Privacy Policy**

**Concierge Medical Associates**

This HIPAA Privacy Policy describes how Concierge Medical Associates ("we," "our," "us") may use and disclose your Protected Health Information (PHI) and your rights regarding your PHI under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

**2. Understanding Your Health Information**

When you visit our practice, we collect information about your health, treatment, and payment for healthcare services. This information is referred to as PHI and includes, but is not limited to, your medical records, billing records, and other identifiable health information.

**3. Uses and Disclosures of PHI**

We may use and disclose your PHI for the following purposes:

- **Treatment**: To provide, coordinate, or manage your healthcare and related services.

- **Payment**: To obtain payment for your healthcare services.

- **Healthcare Operations**: For operational purposes, such as quality assessment, training, licensing, and auditing.

**4. Other Permitted and Required Uses and Disclosures**

We may use or disclose your PHI in the following situations without your authorization:

- **As Required by Law**: When required by federal, state, or local law.

- **Public Health Activities**: For public health reporting and activities.

- **Victims of Abuse, Neglect, or Domestic Violence**: To report abuse, neglect, or domestic violence.

- **Health Oversight Activities**: For audits, investigations, inspections, and licensure.

- **Judicial and Administrative Proceedings**: In response to a court or administrative order.

- **Law Enforcement**: For law enforcement purposes.

- **Research**: Under certain circumstances, for research purposes.

- **Coroners, Medical Examiners, and Funeral Directors**: As necessary to identify a deceased person or determine the cause of death.

- **Organ Donation**: For organ, eye, or tissue donation purposes.

- **Serious Threats to Health or Safety**: To prevent or lessen a serious threat to health or safety.

- **Specialized Government Functions**: For military, national security, or other specialized government functions.

- **Workers' Compensation**: For workers' compensation or similar programs.

**5. Your Rights Regarding Your PHI**

You have the following rights regarding your PHI:

- **Right to Inspect and Copy**: You have the right to inspect and obtain a copy of your PHI.

- **Right to Amend**: You have the right to request an amendment of your PHI if you believe it is incorrect or incomplete.

- **Right to an Accounting of Disclosures**: You have the right to request an accounting of certain disclosures of your PHI.

- **Right to Request Restrictions**: You have the right to request restrictions on the use or disclosure of your PHI.

- **Right to Request Confidential Communications**: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.

- **Right to a Paper Copy of This Notice**: You have the right to a paper copy of this notice upon request.

**6. Complaints**

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer at: muhanad@greenwichdocs.com

**Privacy Officer**  

Concierge Medical Associates  

30 Buxton Farm Rd, Stamford CT 06905 

Phone: 203-646-1188

Email: muhanad@greenwichdocs.co

**7. Changes to This Notice**

We reserve the right to change this notice and make the new notice apply to PHI we already have as well as any information we receive in the future. The current notice will be posted in our office and on our website, and you may request a copy at any time.

**8. Contact Information**

For more information about this notice, please contact our Privacy Officer at the address, phone number, or email address listed above.

---

**Acknowledgment of Receipt**

I acknowledge that I have received a copy of the HIPAA Privacy Policy from Concierge Medical Associates.

**Patient Signature**: _______________________________  

**Date**: ___________________

**Print Name**: _______________________________

---

This template provides a comprehensive HIPAA Privacy Policy for your patients. Customize the placeholders with your practice's specific details.