Last modified: August 16, 2018
Notice of Privacy Practice
The following categories describe different ways that Manhattan Gastroenterology (Dr. Shawn Khodadadian) may use and disclose medical information without your specific consent or authorization. Examples are provided for each category of uses or disclosures. Not all possible uses or disclosures are listed.
For Treatment: We may use and disclose medical information about you to provide you with medical treatment or services. Example: In treating you for specific condition, we may need to know if you are allergic to specific drugs that could influence which medications we prescribe for the treatment purpose.
For Payment: We may use and disclose medical information about you so that treatment and services you receive from us may be billed and payment may be collected from your insurance, third party or you. Example: We may need to send your protected health information, such as your name, address, office visit date and codes identifying your diagnosis and treatment to your insurance company for payment.
Health Care Operations: We may use and disclose medical information about you for health care operations to assure that you receive quality care. Example: We may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you.
Other Uses or Disclosures that Can Be Made Without Consent or Authorization
- As required during an investigation by Law enforcement agencies.
- To avert a serious threat to public health safety.
- As required by military command authorities for their medical records.
- To workers? compensation or similar programs for processing of claims.
- In response to legal proceeding.
- To a coroner or medical examiner for identification of body.
- If an inmate, to the correctional institution or law enforcement official.
- As required by the US Food and Drug Administration (FDA).
- Other healthcare providers treatment activities.
- Other covered entities healthcare operations activities (to the extent permitted under HIPPA).
- Uses and disclosures required by law.
- Uses and disclosures in domestic violence or neglect situations.
- Health oversight activities. 14.Other public activities.
We May Contact You
We may contact you to provide appointment reminders, information about treatment alternatives, or other health related benefits and services that may be of interest to you.
Protected Health Information (PHI)
I understand that, under The Health Insurance Portability Accountability Act of 1996, I have certain rights to privacy in regards to my protected health information (PHI). I have received, read and understood The Notice of Privacy Practices.
I understand that I am formally giving consent to the practice to receive pharmacy and medication information that will be received from any and all outside pharmacies, hospitals or other healthcare institutions. This information may be received electronically via electronic medical record or in writing.
Our practice reserves the right to change the terms of the Notice of Privacy Practices. I understand the Practice will provide me with a copy of its Notice of Privacy Practices on request.
I give permission to the physician and their staff to leave a message on my automated answering device or to family member regarding results of any test or appointments that were done in this office and/ or referred by this office.
983 Park Ave, Ste 1D
New York, NY 10028
Manhattan Gastroenterology- Midtown
51 East 25th Street, 4th Floor
New York, NY 10010