Notice of Privacy Practices for Protected Health Information

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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.

Summit Medical Group, PLLC ("Summit") is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Example of uses of your health information fortreatmentpurposes are:
  • During the course of your treatment, the physician determines he/she will need to consult with another specialist in the area. He/she will share the information with such specialist and obtain his/her input.
Example of use of your health information forpaymentpurposes:
  • We submit requests for payment to your health insurance company. The health insurance company or business associate helping us obtain payment requests information from us regarding your medical care given. We will provide information to them about you and the care given.
Example of Use of Your Information forHealth Care Operations:
    • We may obtain services from business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such business associates as necessary to obtain these services.

    Your Health Information Rights

    The health and billing records we maintain are the physical property of Summit. You have the following rights with respect to your Protected Health Information

    A List of Your Rights
    1. Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office—we are not required to grant the request but we will comply with any request granted;
    2. Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our office;
    3. Right to inspect and copy your health record and billing record—you may exercise this right by delivering the request in writing to our office using the form we provide to you upon request; appeal a denial of access to your protected health information except in certain Circumstances;
    4. Right to request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request. (The physician or other health care provider is not required to make such amendments); you may file a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
    5. Right to receive an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form we provide to you upon request. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
    6. Right to confidential communication by requesting that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office using the form we give you upon request; and,
    To Exercise Your Rights

    If you want to exercise any of the above rights, please contact Summit's Privacy Officer in person or in writing, during normal hours. He will provide you with assistance on the steps to take to exercise your rights.

    Summit's Responsibilities

    We Are Required To:

    Summit is required to:

    • Maintain the privacy of your health information as required by law;
    • Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
    • Abide by the terms of this Notice;
    • Notify you if we cannot accommodate a requested restriction or request; and
    • Accommodate your reasonable requests regarding methods to communicate health information with you.
    • Accommodate your request for an accounting of disclosures.
    • Notify you in the event there is a breach of unsecured protected health information.
    We Reserve The Right To:

    We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy.

    To Request Information or File a Complaint

    如果你有问题,想额外的有限公司mation, or want to report a problem regarding the handling of your information, you may contact:

    Privacy Officer
    1275 Dick Lonas Rd, Suite 201
    Knoxville, TN 37909
    (865) 584-4747

    Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to the Privacy Officer. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office. We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

    Following is a list of other uses and disclosures allowed by the Privacy Rule:

    Patient Contact
    We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you. We may contact you as part of a fund raising effort.
    Notification - Opportunity to Agree or Object
    Unless you object we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

    Communication with Family- Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

    We may use and disclose your protected health information to assist in disaster relief efforts.

    Opportunity to Agree or Object Not Required

    Public Health Activities

    Controlling Disease -As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

    Child Abuse & Neglect- We may disclose protected health information to public authorities as allowed by law to report child abuse or neglect.

    Food and Drug Administration (FDA) -We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

    Employment Related- We may disclose to employers your protected health information to the extent such information is related to medical surveillance or evaluation of a work related injury or illness if the employer needs such information to comply with OSHA rules and regulations.


    We can disclose protected health information to governmental authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment the doctor believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.


    Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities to include audits, civil, administrative or criminal investigations: inspections; licensures or disciplinary actions, and for similar reasons related to the administration of healthcare.


    We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order or administrative tribunal, provided that only the protected health information released is expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process.

    We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, including laws that require reporting of certain types of wounds or other physical injury.

    We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

    Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.
    We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

    为了避免严重威胁健康或安全,我们may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.


    We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

    If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.
    If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

      Other Uses and Disclosures

    • Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization which you may revoke except to the extent information or action has already been taken.


    • If we maintain a website that provides information about our entity, this Notice will be on the website. Please go


    Psychotherapy notes- authorization must be obtained for any use or disclosure of psychotherapy notes except to carry out Treatment, Payment, or Operations or to defend ourselves in a legal action brought by the subject of the notes.

    • Marketing- authorization must be obtained except if the communication is in the form of a face-to-face communication or in the form of a promotional gift by your healthcare provider.
    • ——授权前必须获得任何出售disclosure for the sale of protected health information.