Atlantic Medical Physicians
Revised November 11, 2019
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
At Atlantic Medical Physicians, the privacy of your medical information is important to us. We are committed to treating and using protected healthinformation about you responsibly. This Notice of Health Information Practices describes the personal information We collect and how and when W e use or
disclose that information. It also describes your rights as they relate to your protected health information which does not include Independent Medical
Examinations (IME’s).
Atlantic Medical Physicians may share Protected Health Information between AMP, providers and facilities as necessary to carry out treatment, payment or
health care operations relating to the services rendered at AMP and as otherwise permitted and consistent with this notice. We may share your Protected
Health Information between our providers and facilities. We may do so by means of electronic information exchange through a shared connected andsecure network.
Understanding Your Health Record/Information
Each time you visit Atlantic Medical Physicians, a record of your visit is made. Typically, this record contains your symptoms, examination and test results,
diagnosis, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical records, serves as a:•
Basis for planning your care and treatment•
Means of communicating among the many health professionals who contribute to your care•
Legal documents describing the care you received•
Means by which you or a third-party payer can verify that services billed were actually provided•
A tool in educating health professionals•
A source of data for medical research•
A source of information for public health officials charged with improving the health of this state and nation•
A source of data for our planning and marketing•
A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where
and why others may access your health information, and make more informed decisions when authorizing disclosures to others.
Use and Disclosures of Protected Health Information
We can use or disclose your Protected Health Information for purposes of treatment, payment and health care operations. However, not every particular use
or disclosure that We may make in every category will be listed.
•Treatment: We will use and disclose your protected health information to provide, coordinate or manage your health care and any related services. This
includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as
necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you.
For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary
information to diagnose or treat you. In addition, We may disclose your protected health information from time to time to another physician or health careprovider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health carediagnosis or treatment to your physician.
Health Information Exchange (HIE) – We, along with other health care providers in New Jersey, participate in Jersey Health Connect, a health informationexchange (“HIE”) which allows patient information to be shared electronically through a secured network that is accessible to the providers treating you. We
may disclose your medical information to Jersey Health Connect HIE, unless you opt-out of participating in the HIE.
•Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities thatyour health insurance plan may undertake before it approves or pays for the health care provided to you for protected health necessity, and undertaking
utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to thehealth plan to obtain approval for the hospital admission.
•Health Care Operations: We may use or disclose, as needed, your protected health information in order to conduct certain and operational activities.
These activities include, but are not limited to, quality assessment activities, employee review activities, training of students, licensing, and conducting or
arranging for other business activities.
For example, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room
when your doctor is ready to see you. We may use or disclose your protected health information, as necessary, to contact you by telephone or mail to remind
you of your appointment. We may allow your family and friends to act on your behalf to pick-up your prescriptions, medical supplies, X-rays and similar forms ofProtected Health Information, when we determine, in Our professional judgment that it is in your best interest to make such disclosures.
Special Situations
Subject to the requirements of applicable law, we will make the following uses and disclosures of your Protected Health Information:•Worker’s Compensation. We may release Protected Health Information about you for programs that provide benefits for work-related injuries orillnesses.
•Occupational Health. We may disclose your Protected Health Information to your employer in accordance with applicable law, if We are retained to
conduct evaluation relating to medical surveillance of your workplace or to evaluate whether you have a work-related illness or injury. You will be notified ofthese disclosures by your employer or as required by applicable law.
•Military and Veterans. If you are a member of the Armed Forces, we may release Protected Health Information about you as required by military command
authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
•Public Health Activities. We may disclose Protected Health Information about you for public health activities, including disclosures:to prevent or control disease, injury or disability;
to report births and deaths;
to report child abuse or neglect;
to persons subject to the jurisdiction of the Food and Drug Administration (FDA) for activities related to the quality, safety, or effectiveness of FDA-regulated
products or services and to report reactions to medications or problems with products;
to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
to notify the appropriate government authority if we believe that an adult patient has been the victim of abuse, neglect or domestic violence.
We will only make this disclosure if the patient agrees or when required or authorized by law.
•Health Oversight Activities. We may disclose Protected Health Information to Federal or State agencies that oversee our activities. These activities arenecessary for the government to monitor the health care system, government benefit programs, and compliance with civil rights laws or regulatory programstandards.
•Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Protected Health Information about you in response to a court oradministrative order. We may also disclose Protected Health Information about you in response to a subpoena, discovery request, or other lawful process by
someone else involved in the dispute, but only if We are given assurances that efforts have been made by the person making the request to tell you about therequest or to obtain an order protecting the information requested.
•Law Enforcement. We may release Protected Health Information if asked to do so by a law enforcement official: In response to a court order,
subpoena, warrant, summons or similar process; To identify or locate a suspect, fugitive, material witness, or missing person; About the victim ofa crime under certain limited circumstances; About a death we believe may be the result of criminal conduct; About criminal conduct on Our
premises; and To report a crime, the location of the crime or the victims, or the identity, description or location of the person who committed thecrime.
Coroners, Medical Examiners and Funeral Directors. We may release Protected Health Information to a coroner or medical examiner. Such disclosures
may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release Protected Health Information about
patients to funeral directors as necessary to carry out their duties.
•Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Protected Health Information
about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) toprotect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
•Note. HIV-related information, genetic information, alcohol and/or substance abuse records, mental health records and other specially Protected Health
Information may have certain special confidentiality protections under applicable State and Federal law. Any disclosures of these types of records will be
subject to these special protections. We will obtain your specific authorization or release before using or disclosing these types of information where we are
required to do so by such applicable State and Federal laws. However, we may be permitted to use and disclose such information to our physicians to provide
you with treatment.
Other Uses of Your Health Information
We will always obtain your permission in a written authorization for the following uses and disclosures of Protected Health Information as applicable:•Marketing. We must obtain your written authorization to use and disclose your Protected Health Information for marketing purposes. We may, however,provide you with certain materials or communications face-to-face, or give you promotional gifts of nominal value.
•Sale of PHI. We must obtain your written authorization to disclose your Protected Health Information where we would “sell” or receive any money or othervalue in exchange for disclosing your Protected Health Information to a third party except as otherwise permitted by law.
•Psychotherapy Notes. We must obtain your written authorization to use and disclose psychotherapy notes, except for certain limited treatment,
payment and health care operations purposes.
Your Health Information Rights
Although your health record is the physical property of Atlantic Medical Physicians, the information belongs to you. You have the right to:•
Obtain a paper copy of this notice of information practices upon request (reasonable fee applies)•
Inspect and copy your health record as provided for in 45 CFR 164.524•
Amend your health record as provided in 45 CFR 164.528•
Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528•
Request communications of your health information by alternative means or at alternative locations•
Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522•
Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
You also have the right to receive an accounting of disclosures of Protected Health Information made by us to individuals or entities other than to you for the six(6) years prior to your request. Your requests must be made in writing to the Practice Administrator or Privacy Officer. This request must state the specifictime period(s) and information required. We have the right to charge a reasonable fee and will notify you of the cost involved, and you may choose to withdraw
or modify your request at that time before any costs are incurred.
You have a right to notice in the event a breach occurs affecting your unsecured Protected Health Information. We make every effort to safeguard the privacy
and security of your Protected Health Information as required by law.
Our Responsibilities
Atlantic Medical Physicians is required to:•
Maintain the privacy of your health information•
Provide you with this notice as to our legal duties and privacy practices with respect to information We collect and maintain about you•
Abide by the terms of notice•
Notify you if We are unable to agree to a requested restriction•
Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
We will not disclose your health information without your authorization except as described in this notice. We will also discontinue using or disclosing yourhealth information after We have received a written revocation of the authorization according to the procedures included in the authorization.
Changes to This Notice
We reserve the right to change the terms of this Notice at any time and to make the new Notice effective for all protected health information that We
maintain. If We materially change our policy practices, we will post a copy of the current Notice in our reception area and on our website. You may obtain acopy of the operative Notice from Our receptionist or Privacy Officer.
For More Information or to Report a Problem
If you have questions and would like additional information, you may contact the company’s Practice Administrator, 1500
Allaire Avenue, Ocean, New Jersey 07712 or at 732-988-6300.
If you believe your privacy rights have been violated, you can file a complaint with the company’s Practice Administrator or with the Office for Civil Rights, U.S.
Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Practice Administrator or the Office for Civil Rights.
The address for the OCR is listed below:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independent Avenue, S.W. Room 509F, HHH Building Washington, DC 20201
Revised April 11, 2016

Atlantic Medical Physicians
ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES
By signing this document, I acknowledge that I have read and/or received a copy of the Atlantic Medical
Physicians HIPAA Notice of Privacy Practices______________ Date____________________________________ ______________________________
Printed Name
Patient Signature______________________Atlantic Medical Physicians Use Only_______________________
Date acknowledgement received_________/_________/_________orPatient
Disclosure Information
Reason acknowledgement not obtained__________________________________________________________
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information(PHI). The individual is also provided the right to request that confidential communication of PHI be made by alternative means, such as sending
correspondence to the individual’s office instead of the individual home.

I wish to be contacted in the following manner (check all that apply)Home Telephone________________________

Written Communication

OK to leave message with detailed information

OK to mail to my home address

Leave message with call-back number only

OK to mail to my work/office address
OK to fax to this number _____________

Work Telephone___________________________

Persons authorized to receive information

OK to leave message with detailed information______________________ Relationship _______________

Leave message with call-back number only______________________ Relationship _______________

Cell/Other Telephone____________________________________________ Relationship _______________OK to leave message with detailed information______________________ Relationship _______________

Leave message with call-back numbers only

I do not wish to share information______________________________________ ____________________________________________________
Printed Name
Patient Signature
Date______________________________________
Witness________________
Patient Date of Birth