HIPAA Privacy Policy

How our efforts to comply with HIPAA regulations affects you

The Health Insurance Portability and Accessibility Act of 1996 (HIPAA) requires those of us who manage and control confidential patient information to be accountable for its use and disclosure.

Although HIPAA was originally passed as law in 1996, its effective deadline dates are now upon us. In April 2003, all activities involving confidential patient information (referred to as Protected Health Information) will be under the scrutiny of law, and under the jurisdiction of the Department of Justice, Health and Human Services Department.

In order to be proactive in our efforts toward compliance, Scot B. Glasberg, M.D has adopted methods and processes that must now be followed for each patient.

Every patient (or authorized representative) must authorize the use and disclosure of their protected health information, without exception. If you are a third party, or attorney seeking medical records; you will be required to show proof of such authorization. Additionally, information contained in medical records must only be used or disclosed for specific, and clearly stated purposes. For example: This office will no longer accept requests for an “entire” medical chart/record. You must state the specific information you want, to whom the information is to be disclosed, and the purpose for the use or disclosure of protected health information.

These requirements are non-negotiable, and our staff has no authority to circumvent our policies, so please do not ask them to try. If you have questions regarding this matter please contact our Patient Privacy Advocate, Lisa Villanueva 212-717-8550

The office of Scot B. Glasberg, M.D. has forms that will assist you in providing us with the necessary information. Just ask us, and we will be happy to assist you.

Thanks for your cooperation.

Scot B. Glasberg, M.D.
42A East 74th Street
New York, New York 10021
212-717-8550
Fax 212-717-8589


Consent for Purposes of Treatment, Payment and Healthcare Operations

I consent to the use or disclosure of my protected health information by Scot B. Glasberg, M.D. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Scot B. Glasberg, M.D. I understand that diagnosis or treatment of me by Dr. Scot B. Glasberg may be conditioned upon my consent as evidenced by my signature on this document. I hereby also consent that messages may be left on my home or business phone for the sole purposes regarding my medical appointments or procedures.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Scot B. Glasberg, M.D. is not required to agree to the restrictions that I may request. However, if Dr. Scot B. Glasberg agrees to a restriction that I request in writing, the restriction is binding.

I have the right to revoke this consent, in writing, at any time, except to the extent that Dr. Scot B. Glasberg has taken action in reliance on this consent.

My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review Scot B. Glasberg, M.D.’s Notice of Privacy Practices prior to signing this document. Scot B. Glasberg, M.D.’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Scot B. Glasberg, M.D. The Notice of Privacy Practices for Scot B. Glasberg, M.D. is also provided and available upon request at our Manhattan office, from our billing office in Florida and on Dr. Scot B. Glasberg’s website at www.DrGlasberg.com. This Notice of Privacy Practices also describes my rights and Scot B. Glasberg, M.D.’s duties with respect to my protected health information.

Scot B. Glasberg, M.D. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

Download HIPAA Privacy Policy Form