Notice of Privacy Practices


Our Legal Duty Under HIPPA

Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) we are required to maintain the privacy of your protected health information.  In accordance with these state and federal laws, we are required to give you this notice about our privacy practices, our legal duties and your rights concerning your medical information.  This notice describes how your personal medical information may be used and disclosed, and how you can get access to this information.  Please review it carefully.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care service to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

  1. 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, your protected health information may be provided to a physician or other medical facility to which you have been referred to ensure that the physician or facility has the necessary information to diagnose or treat you.
  2. Payment
    Your protected health information will be used, as needed, to obtain payment for your health care services.  For example, obtaining approval for an outpatient procedure may require that your relevant protected health information be disclosed to the health plan to obtain approval for the procedure.
  3. Healthcare Operations 
    We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical residents, licensing, and conducting or arranging for other business activities.  We may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician.  We may also call you by name in the waiting room when your physician is ready to see you.

    We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization.  These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroner, Funeral Directors and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section164.500.

    Other permitted and required uses and disclosures will be made only with your written consent, authorization or opportunity to object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.      

Your Rights

The following is a statement of your rights regarding your protected health information.

  1. You have the right to inspect and copy your protected health information.
    Under Federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
  2. You have the right to request a restriction of your protected health information.
    This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations.  You may also request that any part of your protected health information not be disclosed to family members or friend who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must be in writing and state the specific restriction requested and to whom you want the restrictions to apply. Your physician is not required to agree to a restriction that you may request.  If a physician believes it is in your best interest to permit the use and disclosure of your protected health information, your protected health information will not be restricted.  You then have the right to use another Healthcare Professional.
  3. You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
    You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.
  4. You may have the right to have your physician amend your protected health information.
    If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide with a copy of any such rebuttal.
  5. You have the right to receive an accounting of certain disclosures we have made, of any of your protected health information.
    We reserve the right to change the terms of this notice and will inform you by mail of any changes.  You then have the right to object or withdraw your authorization as provided in this notice.
  6. Complaints
    You may complain to the Secretary of Health and Human Services or us if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying our privacy contact of your complaint.  We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information.  If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person by phone at our main number. Contact numbers for the above are available an on display in our office.


Bender Orthopaedics & Spine Specialist
11660 Alpharetta Highway, Suite 630
Roswell, GA 30076
Phone: 678-831-8915
Fax: 678-297-7587

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