Describes how health info about you may be used and disclosed, and how to get access to this information.
Eileen C. Comia, MD LLC is required by applicable Federal and State law to maintain the privacy of your protected health
information (PHI). We are required to provide you with this Notice regarding our duties and practices in using your health
information. We shall abide by the terms of this Notice which will remain in effect until we replace it.
Eileen C. Comia, MD LLC reserves the right to change its privacy practices and the terms of this Notice at any time. It
reserves the right to have the changes apply not only to health information acquired after the change in Notice, but also to
health information received before the change in Notice. Should our Notice be revised, we will make the new Notice
available upon request.
Eileen C. Comia, MD LLC may use and disclose protected health information (PHI) about you for the following purposes
without obtaining your written consent:
To provide treatment (e.g. discussions between caregivers or other healthcare providers for coordination and
planning of your care). Treatment means provision of healthcare and related services, including consulting between
healthcare providers; and referring you to another healthcare provider to receive care;
To obtain payment for the service we provide to you.
To conduct our administrative and business operations, which includes, but is not limited to, conducting quality
improvement activities, reviewing the competence or qualifications of healthcare professionals, case management
and care coordination, contacting patients with information regarding treatment alternatives, conducting or arranging
for legal counsel, medical review and auditing functions including fraud and abuse detection.
Unless you object or specifically request to restrict use, Eileen C. Comia, MD LLC may communicate health information: (a)
to your family member/s, legally authorized representative/s, and any other person identified by you which is directly
relevant to such person’s involvement in your care or payment for your care; and (b) to notify or assist in the notification of a
family member, a personal representative, or any other person responsible for you. If you are able, we will provide you with
the opportunity to consent or object to such disclosure. If you are unable to object due to your incapacity or an emergency
circumstance, Eileen C. Comia, MD LLC, based upon its professional judgment, will make such disclosure if it determines
that it is in your best interest to do so. Such disclosure of health information will be limited to information that is directly
relevant to the recipient’s involvement with your healthcare.
Unless the health information is protected by Federal/State confidentiality laws, we may use and disclose your health
information without your consent or without providing you the opportunity to object as follows:
If the use or disclosure of health information is required by law and is limited to the relevant requirements of the
Disclosures required by law to state and federal public health authorities;
Disclosures made to government authorities for the purpose of reporting suspected abuse and neglect of children, the
elderly, and the mentally retarded;
Disclosures to health oversight agencies authorized by law, in connection with audits, civil, administrative, or
criminal investigations, licensure or disciplinary actions; or for monitoring compliance and quality;
Disclosures to persons exposed to a communicable disease if authorized by law to make such disclosure;
Disclosures in connection with judicial and administrative proceedings in response to an order of the court or
administrative tribunal, or in response to a lawfully issued subpoena;
Disclosures to law enforcement if mandated by law;
Disclosures to law enforcement if there is evidence of criminal conduct that occurred on the office’s premises;
Disclosures to persons reasonably able to prevent or lessen serious and imminent threat to the health or safety of a
person or the public; or if necessary to apprehend an individual involved in a violent crime that we believe may have
caused serious physical harm to you;
Eileen C. Comia, MD LLC may make disclosures of your health information to provide follow-up contact to you regarding
upcoming appointments, treatment alternatives, health-related benefits, programs, services, events and functions which may
be of interest to you. We may use health information to provide you with appointment reminders (such as voicemail
messages, postcards, or letters).
You acknowledge and agree that Eileen C. Comia, M.D. LLC will enter your protected health information (“PHI”) in a
database maintained by the Saint Francis Hospital and Medical Center (the “Hospital”). The PHI maintained in the database
will be used by Eileen C. Comia, M.D. LLC for treatment, payment and health care operations purposes. Eileen C. Comia,
M.D. LLC may also disclose your PHI maintained in the database to another provider (i) for treatment purposes, (ii) for
payment purposes and (iii) for health care operations if you have or had a relationship with the other provider and only for the
following reasons: (a) conducting quality assessment and improvement activities, including outcomes evaluation and
development of clinical guidelines, provided that the obtaining of generalizable knowledge is not the primary purpose of any
studies resulting from such activities; population-based activities relating to improving health or reducing health care costs,
protocol development, case management and care coordination, contacting of health care providers and patients with
information about treatment alternatives; and related functions that do not include treatment; or (b) reviewing the competence
or qualifications of health care professionals, evaluating practitioner and provider performance, health plan performance,
conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to
practice or improve their skills as health care providers, training of non-health care professionals, accreditation, certification,
licensing, or credentialing activities; or (c) health care fraud and abuse detection or compliance. Eileen C. Comia, M.D. LLC
may also disclose your PHI maintained in the database to the Saint Francis Physician Hospital Organization (“PHO”) for use
by the PHO as a Business Associate of the Group for health care operational purposes, including without limitation, quality
and utilization review of health care services.”
All other uses or disclosures will only be made with your specific written authorization, which may be revoked, except
to the extent it has already been relied upon. In all cases, when information about you or your child is released, we
will disclose only the minimum amount of information necessary to address the purpose of the request.
You have the right to request certain restrictions on the use of your protected health information for treatment,
payment, and our operations, disclosures to notify family and friends of your general condition, and disclosures to
others involved in your care or payment of your care. However, we are not required to honor all such restrictions.
The right to request that we communicate with you about your health information by alternative means or to
alternative locations. (You must make your request in writing.) Your request must specify the alternative means or
location, and provide satisfactory explanation how payments will be handled under the alternative means or location
you request.
Most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and
disclosures that constitute a sale of PHI require patient authorization.
Other uses and disclosures not described in this Privacy Notice will be made only with authorization from the
You have the right to restrict certain disclosures of PHI to health plans/insurances if the patient pays out of pocket in
full for the health care service.
You have the right to look at or get copies of your health information, with limited exceptions. You may request
that we provide copies in a format other than photocopies. We will use the format you request unless we cannot
practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain
a form to request access by contacting the Center. We will charge you a reasonable cost-based fee for expenses such
as copies and staff time. Contact us for a full explanation of our fee structure.)
You have the right to receive a list of instances in which we disclosed your health information for purposes other
than treatment, payment, and healthcare operations. If you request this accounting more than once in a 1-year period,
we may charge you a reasonable, cost-based fee for responding to these additional requests.
Affected patients have the right to be notified following a breach of unsecured PHI.
You have the right to request that we amend your health information. (Your request must be in writing, and it must
explain why the information should be amended.) We may deny your request under certain circumstances.
If you receive this Notice on our website or by electronic mail (email), you are entitled to receive this Notice in
written form.
If you believe Eileen C. Comia, MD LLC has violated your privacy rights, you may file a complaint to us or to the
Department of Health and Human Services. Please send a written complaint to:
Eileen C. Comia, MD LLC
35 Jolley Drive Suite 102
Bloomfield, CT 06002
Attn: Julius A. Comia, M.D. - Manager
If you would like more information regarding our privacy practices, please contact the office at (860)242-2200.
Name of Patient: ______________________________________ Date of Birth: _________________
Can patient be contacted by phone: Y N Tel no. ( _____ ) _____________________
Can messages be left on voicemail: Y N
Can patient be contacted via email: Y N Email: ___________________________________
Can messages be left with another person: Y N
Can phone messages be left at work: Y N
Can patient be contacted by mail: Y N
Can messages/notes be faxed to patient: Y N Fax no. ( ____ ) _______________________
Other authorized party to speak on behalf of patient: ____________________________________
This is to acknowledge that I have received and read the medical practice’s Notice of Privacy Practices.
I further acknowledge that a copy of the current notice will be posted in the reception area, and that I may request a copy of any
amended Notice of Privacy Practices at each appointment.
Signature of Patient / Guardian: _________________________________ Date: __________________
If not signed by patient, please indicate relationship to patient:
Relationship: __________________________ Witnessed by: ________________________
Internal Use Only:
If patient or patient’s representative refuses to sign acknowledgement of receipt of notice, please document
the date and time the notice was presented to patient and sign below.
Presented on (Date and Time): ______________________________________
By (Name and Title): _____________________________________________
Eileen C. Comia, M.D. LLC
35 Jolley Drive Suite 102 Bloomfield, CT 06002
Tel (860)242-2200 Fax (860)242-2212