Online Pre-Registration

Canadian residents - If you have not yet done so, please
read all information for Canadian patients before continuing.

Notice of Privacy Practices for Dr. William Graber and Dr. Matthew Fitzer

This notice describes how medical information about you may be used and disclosed and how you get access to this information. Please review it carefully, then fill out the information at the bottom of the page.

Uses and Disclosures: We will use and disclose elements of your protected health information (PHI) in the following ways:

Without your signed authorization

Treatment eg. Consultants, specialists, laboratories
Payment eg. Health insurers, billing services
Health care operations eg. business planning, quality assurance
When release is required by law, including judicial settings and to health oversight regulatory agencies and law-enforcement
In emergency situations or to avoid serious health or safety situations
To medical examiners, coroners or funeral directors to aid in identifying you or to help them in performing their duties
To organ, tissue and other donation organizations upon or proximate to your death, if we have no indication on hand and by your donation preferences (a positive indication)

Special Cases

To contact you about appointment reminders, treatment alternatives and other health-related benefits and services
In fund-raising for ourselves
To the sponsor of your health plan

Other

All other use and disclosure by us will require us to obtain from you a written authorization in addition to any other permission you will provide us

Your Rights: You have the following rights concerning your PHI.

Restrictions: Request restricted access to all or part of your PHI. To do this, contact Ms. Sullivan in my office. We are not required to grant your request.
Confidential communications: To receive correspondence of confidential information by alternative means of location. To do this, contact Ms. Sullivan.
Access: To inspect or receive of your PHI. To do this, contact Ms. Sullivan.
Accounting: To receive an accounting of the disclosure by us of your PHI in the 6 years prior to your request. To do this, contact Ms. Sullivan.
This notice: To get updates or reissue this notice, at your request.
Complaints: To complain to us or to the United States Department of Health and Human Services if you feel your privacy rights have been violated. To register a complaint with us contact Ms. Sullivan. The law forbids us from taking retaliatory action against you if you complain.

Our duties: We are required by law to maintain the privacy of your PHI. We must abide by the terms of this notice and or any updates of this notice.

Privacy contact: For more information about our privacy practices, please contact Ms. Sullivan at 315-624-4740, 1724 Burrstone Road, New Hartford, New York 13413 in writing.

Effective date: This notice is effective April 15, 2003

	I have read the above information. I understand that I will have the opportunity to ask questions during my initial consult.
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Please note you must fully complete the online registration during this session. The whole process will take approximately 45 minues.