Patient Privacy Statement


Each time you visit our office, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing information. This notice applies to all of the records of your care generated by us, whether made by your physician or our employees. This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. Your "protected health information" means any of your written, electronic, and orally transmitted health information, including demographic data that can be used to identify you. This is health information that is created or received by a health care provider and relates to your past, present, or future physical or mental health condition.

We are required by law to maintain the privacy of your protected health information and provide you a description of our privacy practices. We are required to abide by the terms of this Notice.

We ask that you sign a written acknowledgment that you have had the opportunity to read our Notice and to obtain a copy of it if requested. The following categories describe examples of the way we may use and disclose medical information about you.

FOR TREATMENT We may use medical information about you to provide, coordinate, or manage your health care and related services. We may disclose medical (and personal) information about you to other doctors, nurses, technicians, allied health professionals, hospital and medical and administrative personnel who are involved in taking care of you. We may provide a subsequent health care provider with copies of various reports that should assist the provider in treating you. Medical care assistance that is provided by your family members or others will require revealing information about you and your treatment. In some cases, we may also disclose your protected health information to an outside treatment provider for purposes of the treatment activities of the outside provider.

FOR PAYMENT We may use and disclose information in your health record about you and your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about you and your treatment so they will pay us or reimburse you for the treatment. We may also tell your health plan, your insurance company, or the party responsible to pay your bill about any proposed treatment to determine whether your plan or the responsible party will cover it. We may also disclose patient information to another health care provider involved in your care for the other health care provider's payment activities.

FOR HEALTH CARE OPERATIONS We may use and disclosure medical information about you and your treatment to assess the care and outcomes in your case and others like it. The information may then be used for quality assessment and improvement activities. For example, we may combine medical information about many patients to evaluate the need for new services or treatment. We may disclose information to other doctors, nurses, and students for educational purposes. We may combine medical information we have with that of other practices to see where we can make improvements. We may also use and disclose your medical information:

  1. To remind you that you have an appointment for medical care;
  2. To assess your satisfaction with our services;
  3. To tell you about possible treatment alternatives;
  4. To tell you about health–related benefits or services;
  5. To conduct training programs or review competence of our employees;
  6. For review and auditing, including compliance reviews, medical reviews, and maintaining compliance programs;
  7. For business management, general administrative activities, and legal services.

Although your health record is the physical property of our practice, you have the right to:

Inspect and Copy You have the right to inspect and obtain a copy of your health information. Usually, this includes medical and billing records. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by us will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

The fee for receiving a copy of your protected health information is established by Louisiana law. You will be charged a copying fee of $1.00 per page for the first 25 pages, .50 per page for pages 26-500, and .25 per page thereafter. A handling charge of $7.00 also will be assessed as well as actual postage, if applicable.

Amend If you feel that medical and related information we have about you is incorrect or incomplete, you may request that we amend your record. You have the right to request an amendment for as long as the information is kept by or for the Practice. This request must be in writing and must include reason(s) to support the request. We may deny your request for an amendment and, if this occurs, you will be notified of the reason for the denial.

An Accounting of Disclosures You have the right to request an accounting of disclosures. This is a list of certain disclosures we make of your medical record for purposes other than treatment, payment or health care operations.

Request Restrictions You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. For example, you could ask that we not use or disclose information about an illness you have had. We will investigate our ability to meet the request prior to agreeing to any restriction and may deny a request under certain circumstances. Requests for such restrictions must be presented in writing to our contact person.

Request For Confidential Communications You have the right to request that we communicate with you about your medical matters in a certain way or at a certain location. For example, you may ask that we contact you at your place of employment or by U.S. Mail. We will grant requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing to our contact person and the written request includes a mailing address where you are able to receive bills for services rendered by us and related correspondence regarding payment for services. Please realize that we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

A Paper Copy of This Notice You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. A copy of the Notice can be obtained from our contact person or at the front desk.


We reserve the right to change this Notice. A revised or changed Notice will be effective for information we already have about you as well as any information we receive in the future. The current Notice will be posted at or near the front desk and include the effective date. In addition, each time you visit us for treatment or health care services, we will provide, at your request, a copy of the current Notice in effect.


Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we already have made with your permission and that we are required to retain our records of the care that we provided to you.

Federal regulations permit your protected health information to be used and disclosed for the following purposes without your written permission or opportunity to object:

  1. When required by state or federal law, for example:
    • Disclosures about victims of abuse, neglect, or domestic violence
    • Disclosures for judicial (court) or administrative proceedings
    • Disclosures for law enforcement purposes
  2. To public health authorities;
  3. To health oversight agencies for activities necessary for the appropriate oversight of the health care system and government benefits programs (for example, Medicare and Medicaid), as well as compliance with regulatory programs and civil rights laws;
  4. When reporting a crime on our premises or reporting a crime in emergencies;
  5. Disclosures to the coroner to assist in the identification of a deceased person, determining a cause of death, or other duties authorized by law;
  6. Disclosures to funeral directors as necessary to carry other their duties;
  7. Disclosures to avert a serious threat to health or safety;
  8. Disclosures to the Food and Drug Administration (FDA) to aid the agency in assessing the quality, safety or effectiveness of an FDA-regulated product or activity;
  9. Disclosures for national security and intelligence activities, for the protective services for the President, and for medical suitability determinations for the Department of State;
  10. Disclosures necessary to comply with laws regulating workers’ compensation.


There are some services provided by us through contacts with business associates. Examples include processing of certain laboratory tests and a medical transcription service. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate through contract to appropriately safeguard your information.


We may release medical information about you to a family member or a close personal friend who is directly involved in your medical care or who helps pay for your care. In addition, we may disclose medical information about you in the event of a disaster to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

RESEARCH We may disclose information to researchers when an institutional review board has reviewed and approved a research proposal and has established protocols to ensure the privacy of your health information.

FUTURE COMMUNICATIONS We may communicate to you via newsletters or other means regarding treatment options, health information, disease management programs, wellness programs, or activities we are participating in or recommending for your treatment or health care services.


If you believe your privacy rights have been violated, you may file a complaint with us by contacting the Office Manager. Those individuals can be located by asking the person at the front desk to have them meet with you at your convenience. You may also contact the Secretary of the Department of Health and Human Services and provide them, in writing, your complaint or send it electronically. Their address is The U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201, telephone: 202-619-0257, toll free: 1-877-696-6775


If you have any questions about this Notice, please contact the Office Manager either by asking for her or him at the front desk or by contacting them via phone or in writing (ATTN: Office Manager) to the appropriate location:

Drs. Millet, Kesler, Brinkman, Cuccia & Delcham 80 Gardenia Drive
Ste. B
Covington, LA 70433
Drs. Baier, Keefer, Long, Miles & Kerkow 201 St. Ann Drive
Ste. B
Mandeville, LA 70471
Practice Administrator for St. Tammany Physicians Network 201 St. Ann Drive
Ste. B
Mandeville, LA 70471


You may also contact the Office Manager for additional information about the following:

  1. Your right to inspect and obtain a copy of your health information;
  2. Your right to request and amend your record;
  3. Your right to request an accounting of disclosures;
  4. Your right to request restriction or limitation on the medical information;
  5. Your right to request that we communicate with you about medical matters in a certain way or at a certain location.