Opening August 2022
Signed in as:
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
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
Appointment reminders. Your health information will be used by our staff to send you
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.
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
● The right to receive confidential communications concerning your medical condition
● 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
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
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.
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
You will not be penalized or otherwise retaliated against for filing a complaint.
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
This notice is effective on or after 4/1/2022.
Sult Family Medicine
710 East 9th Street, Rochester, Indiana 46975, United States
Copyright © 2022 Sult Family Medicine - All Rights Reserved.
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