Privacy Policy

Sult Family Medicine

Notice of Privacy Practices

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.

Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed to

other health care professionals for the purpose of evaluating your health, diagnosing

medical conditions, and providing treatment. For example, results of laboratory tests

and procedures will be available in your medical record to all health professionals who

may provide treatment or who may be consulted by staff members.

Payment. Your health information may be used to seek payment from your health plan,

from other sources of coverage such as an automobile insurer, or from credit card

companies that you may use to pay for services. For example, your health plan may

request and receive information on dates of service, the services provided, and the

medical condition being treated.

Health care operations. Your health information may be used as necessary to support

the day ­to ­day activities and management of Sult Family Medicine, LLC. For example,

information on the services you received may be used to support budgeting and

financial reporting, and activities to evaluate and promote quality.

Law enforcement. Your health information may be disclosed to law enforcement

agencies to support government audits and inspections, to facilitate law­ enforcement

investigations, and to comply with government mandated reporting.

Public health reporting. Your health information may be disclosed to public health

agencies as required by law. For example, we are required to report certain

communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization. Disclosure of your health

information or its use for any purpose other than those listed above requires your

specific written authorization. If you change your mind after authorizing a use or

disclosure of your information you may submit a written revocation of the authorization.

However, your decision to revoke the authorization will not affect or undo any use or

disclosure of information that occurred before you notified us of your decision to revoke

your authorization.

1. Additional Uses of Information

Appointment reminders. Your health information will be used by our staff to send you

appointment reminders.

Information about treatments. Your health information may be used to send you

information that you may find interesting on the treatment and management of your

medical condition. We may also send you information describing other health ­related

products and services that we believe may interest you.

Patient mass communication. Unless you request us not to, we will use your name

and e-mail address(es) and/or text numbers to contact you with bulk messaging. For

instance, to share new promotions for the clinic, to send clinic newsletters, or to notify

you of a physician's upcoming absence, such as for a vacation.

Individual Rights

You have certain rights under the federal privacy standards.  These include:

● The right to request restrictions on the use and disclosure of your protected health

information

● The right to receive confidential communications concerning your medical condition

and treatment

● The right to inspect and copy your protected health information

● The right to amend or submit corrections to your protected health information

● The right to receive an accounting of how and to whom your protected health

information has been disclosed

● The right to receive a printed copy of this notice

Sult Family Medicine’s Duties

We are required by law to maintain the privacy of your protected health information and

to provide you with this notice of privacy practices.

We also are required to abide by the privacy policies and practices that are outlined in

this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and

practices. These changes in our policies and practices may be required by changes in

federal and state laws and regulations. Upon request, we will provide you with the most

recently revised notice on any office visit. The revised policies and practices will be

applied to all protected health information we maintain.

Requests to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we maintain.

As permitted by federal regulation, we require that requests to inspect or copy protected

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Revised  4/25/22

health information be submitted in writing. You may obtain a form to request access to

your records by contacting Dr. Jennifer Sult. Your request will be

reviewed and will generally be approved unless there are legal or medical reasons to

deny the request.

Complaints

If you would like to submit a comment or complaint about our privacy practices, you can

do so by sending a letter outlining your concerns to:

Jennifer Sult, MD

710 E. 9th Street

Rochester, IN, 46975 

If you believe that your privacy rights have been violated, you should call the matter to

our attention by sending a letter describing the cause of your concern to the same

address.

You will not be penalized or otherwise retaliated against for filing a complaint.

Contact Person

The name and address of the person you can contact for further information concerning

our privacy practices is:

Jennifer Sult MD

710 E. 9th Street 

Rochester, IN 46975

Effective Date

This notice is effective on or after 4/1/2022.