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, please contact our privacy officer, whose her contact information is at the bottom of this notice. If you are signing this form electronically, you may contact the privacy officer via our website.

• Freeman-Sheldon Research Group, Inc. provides research-related healthcare to our patients in partnership with other professionals. We are not a university- or hospital-affiliated organisation, but many of our members have personal affiliations with universities and hospitals. The information privacy practices in this notice will be followed by all FSRG members, regardless of location or other affiliation they may have. This includes FSRG employees, medical staff, trainees, students, or volunteers. FSRG may share your health information for coordination of care, treatment, and healthcare operations purposes.

• We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. We are required by law to: keep medical information about you private, give you this notice of our legal duties and privacy practices with respect to medical information about you, and follow the terms of the notice that is currently in effect.

Use and Disclosure Not Requiring Specific Informed Consent
• We may use and disclose medical information about you without your prior authorisation for treatment, such as sending medical information about you to a specialist as part of a referral) (this includes psychiatric or HIV information, if needed for purposes of your diagnosis and treatment) and to support our healthcare operations, such as comparing patient data to improve treatment methods or for professional education purposes. If you are treated in a specialised substance abuse programme, your special authorisation will be needed for most disclosures other than emergencies.
• Other examples of such uses and disclosures include contacting you for appointment reminders and telling you about or recommending possible treatment options, alternatives, health-related benefits or services that may be of interest to you. We may also contact you to support our fund-raising efforts.
• We may use or disclose medical information about you without your prior authorisation for several other reasons. Subject to certain requirements, we may give our medical information about you, without prior authorisation for public health purposes, abuse or neglect reporting, health oversight audits or inspections, medical examiners, emergencies, national security and other specialised government functions, and for members of the Armed Forces, as required by Military Command authorities. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders or other legal process. We may disclose medical information about you to a friend or family member whom you designate or in appropriate circumstances, unless you request a restriction.

Use and Disclosure Requiring Specific Informed Consent
• Under certain circumstances, we may use and disclose health information about you for research purposes, subject to a special approval process. We may also allow potential researchers to review information that may help them prepare for research, so long as the health information they review does not leave our facility, and so long as they agree to specific privacy protections.
• In any other situation not covered by this notice, we will ask for your written authorisation before using or disclosing medical information about you. If you chose to authorise use or disclosure, you can later revoke that authorisation by notifying us in writing or your decision.

Right to Access and Amend Your Records
• In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care, when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing, or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.
• If you believe that information in your record is incorrect or that important information is missing, you have the right to request that we correct the records, by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend a record if the information is not maintained by us; or if we determine that your record is accurate. You may submit a written statement of disagreement with a decision by us not to amend a record.

Right to an Accounting
• You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment and healthcare operations, circumstances in which you have specifically authorised such disclosure and certain other exceptions. To request this list of disclosures, indicate the relevant period which must be after 14 April 2003, but in no event for more than the last six years. You must submit your request in writing to the privacy officer.

Right to Request Restrictions and Confidential Communications
• You may request, in writing, to our privacy officer that we not use or disclose medical information about you for treatment, healthcare operations, or to persons involved in your care, except when specifically authorised by you, required by law, or in an emergency. We will consider your request and work to accommodate it when possible, but we are not legally required to accept it. We will inform you of our decision on your request.
• You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us of the specific way or location for us to use to communicate with you.

Changes to this Notice and Right to Request a Hard-copy
• We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. Before we make a significant change in our policies, we will change our notice and post in our facilities and on our Web site at
• You can receive a copy of the current notice at any time. The effective date is listed at the end. Copies of the current notice will be available each time you come to our facility. You will be asked to acknowledge in writing your receipt of this notice. You may receive a paper copy of this Notice from us upon request, even if you have agreed to receive this notice electronically.

• If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer listed below or via our website, if you are signing this form electronically. If you are not satisfied with our response, you may send a written complaint to the US Department of Health and Human Services Office of Civil Rights. Our privacy officer can provide you the address. Under no circumstances will you be penalised or retaliated against for filing a complaint.

Acknowledgement of Receipt of Notice of Privacy Practices *
In signing below, I affirm that I (1) have received a copy of the privacy practices; (2) read and understand the consent; and (3) agreed to comply and be bound by the consent. If you do not agree, state 'NA'.
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Patient Name *
If the patient signed, state 'self'.
Your answer
Patient Date of Birth *
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Relationship to Patient *
If patient signed, state 'NA'.
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Reason for Refusal to Sign *
If not refused, state 'NA'.
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