TARAL SHARMA, MD, PC

120 PELHAM LN

Phone: (864) 844 – 9432

Fax: (864) 844-9430

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this Notice, please contact:
Drew Hedden at 864-844-9432, Extension-309

WHO WILL FOLLOW THIS NOTICE?

We understand that medical information about you and your health is personal and are committed to protecting this information. When you receive care at Taral Sharma, MD, PC, a record of the care and services you receive is made. Typically, this record contains your treatment plan, history and physical, test results, and billing record. This record serves as a:

This Notice tells you the ways we may use and disclose your Protected Health Information (referred to herein as “medical information”). It also describes your rights and our obligations regarding the use and disclosure of medical information.

OUR RESPONSIBILITIES.

Taral Sharma, MD, PC shall:

THE METHODS IN WHICH WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways we may use and disclose your medical information. The examples provided serve only as guidance and do not include every possible use or disclosure.

SPECIAL SITUATIONS.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

You have the following rights regarding medical information collected and maintained about you:

CHANGES TO THIS NOTICE.

We reserve the right to change our practices and to make the new provisions effective for all PHI we maintain. Should our information practices change, we will post the amended Notice of Privacy Practices in our office and on our website. You may request that a copy be provided to you by contacting the Privacy Officer.

COMPLAINTS.

If you believe your privacy rights have been violated, you may file a complaint with Taral Sharma, MD, PC or with the Office for Civil Rights, U.S. Department of Health and Human Services. To file a complaint with Taral Sharma, MD, PC, contact the Privacy Officer at 864-844-8112, Extension-700. Your complaint must be filed within 180 days of when you knew or should have known that the act occurred. The address for the Office of Civil Rights is:

Secretary of Health & Human Services
Office for Civil Rights
U.S. Department of Health and Human Services
P. O. Box 8206, Columbia, SC 29202-8206

All complaints should be submitted in writing.
You will NOT be penalized for filing a complaint.

ACKNOWLEDGEMENT
Patient Name:
Date of Birth:
Social Security Number:

I UNDERSTAND THAT TARAL SHARMA, MD, PC WILL FILE YOUR INSURANCE AND THAT ALL MONIES FOR SERVICES RENDERED ARE DUE ON THE DAY OF SERVICE.
I acknowledge that Taral Sharma, MD, PC provided me with a written copy of Notice of Privacy Practices.
I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.

Patient Signature:
Date:
Personal Representative Signature (if applicable)
Relationship to Patient: