Online Registration

Notice of Privacy Practices for William A. Graber, MD, PC

This notice describes how medical information about you may be used/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 e.g., consultants, specialists, laboratories
Payment e.g., health insurers, billing services
Health care operations e.g., 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 Indication

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

Other

All other uses 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 placement of restricted access to all or part of your PHI. To do this, contact the Office Administrator, Theresa Sullivan, in the office. We are not required to grant your request.

Confidential communication: To receive correspondence of confidential information by alternative means of communication. To do this, contact Theresa Sullivan.

Access: To inspect or receive copies of your PHI. To do this, contact Theresa 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 Theresa Sullivan.

This notice: To get updates or reissue of 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 Theresa 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 Theresa Sullivan at 1-877-269-0355, 1724 Burrstone Road, New Hartford, NY, 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.
First Name:
Last Name:
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Please have your insurance cards, all medication/supplement bottles, and the names and phone numbers of all your doctors and specialists close by before you begin online registration process. Please complete the brief registration process in one sitting; you are not able to log in and out of the registration portion of our website. This process may take up to 45 minutes to complete. Please call 1-877-269-0355 with any questions.

This site is secure and password-protected and only you and our office have access to your personal data.