Patient Information

Now accepting new patients!

Women over the age of 18 or who are sexually active are encouraged to see a GYN once each year for their annual exam. Being proactive is an essential part of maintaining a healthy lifestyle. If you would like to save time at your first appointment, we invite you to download and fill out our new patient paperwork.

The following is some information that you might find helpful.

Insurance Information
We participate with most major medical insurances. Please call for specific information.  Co-pays are due at the time of the visit.

Hospital Affiliations
Patient Privacy

Chouchani Sayegh and Bagnarello MD LLP. HIPAA NOTICE OF PRIVACY PRACTICES Effective Date (January 1st, 2007)

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. If you have any questions about this notice, please contact: Chouchani Sayegh and Bagnarello MD LLP at 716-633-6363. This notice describes the privacy practices at our office.

 

We are required by law to:
– Maintain the privacy of protected health information.

– Give you this notice of our legal duties and privacy practices regarding your health information

– Follow the terms of the notice currently in effect.

 

How we may use and disclose your health information:
Described as follows are the ways we may use and disclose your health information. Except for the following purposes we will use and disclose your health information only with your written permission. You may revoke such permission at any time by writing to Gabriel Emile Chouchani.

 

Treatment:
We may use and disclose your health information for your treatment and to provide you with treatment- related health care services. For example, we may disclose your health information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.
Payment. We may use and disclose your health information so that others or we may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received. For example, we may give information to your health plan so that they will pay for your treatment.

 

Health Care Operations:
We may use and disclose your health information to evaluate and improve our medical care and to operate and manage our office. For example, we may use and disclose information to a peer review organization or a health plan that is evaluating our care. We may also share information with others that have a relationship with you for their health care operation activities.
Appointment Reminders, Treatment Alternatives, and Health- Related Benefits and Services. We may use and disclose your health information to contact you and remind you of your appointment, to tell you about treatment alternatives or health-related benefits and services you could use.

 

Individuals Involved in Your Care or Payment for Your Care:
When appropriate, we may share your health information with a person involved in, or paying for, your care (such as your family or a close friend). We may notify your family about your location or condition or disclose such information to an entity assisting in disaster relief.

 

Research:
We may use and disclose your health information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another for the same condition. Before we do so, the project needs to go through a special approval process. Even without special approval, we may permit researchers to look at records to help identify patients who may be included in their research, as long as they do not remove or copy any of your health information.

 

As Required by Law:
We will disclose your health information when required to do so by international, federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose your health information when necessary to prevent a serious threat to the health and safety of you, another person, or the public. Disclosures will be made only to someone who can prevent the threat.

 

Business Associates:
We may disclose your health information to our business associates that perform functions on our behalf or provide us with services if necessary. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose the information for any other purpose than appears in their contract with us.

 

Military and Veterans:
If you are a member of the armed forces, we may release your health information as required by military command authorities. If you are a member of a foreign military we may release your health information to the foreign military command authority.
Worker’s Compensation. We may release your health information for worker’s compensation or similar programs that provide benefits for work-related injuries or illness.

 

Public Health Risks:
We may disclose your health information for public health activities to prevent or control disease, injury or disability. We may use your health information in reporting births or deaths, suspected child abuse or neglect, medication reactions or product malfunctions or injuries, and product recall notifications. We may use your health information to notify someone who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. If we are concerned that a patient may have been a victim of abuse, neglect, or domestic violence we may ask your permission to make a disclosure to an appropriate government authority. We will make that disclosure only when you agree or when required or authorized to do so by law.

 

Health Oversight Activities:
We may disclose your health information to a health oversight agency for activities authorized by law. These may include audits, investigations, inspections, and licensure. These activities are necessary to for the government to monitor the health care system, government programs, and compliance with civil rights laws.

 

Lawsuits and Disputes:
If you are involved in a lawsuit or dispute, we may disclose your health information in response to a court or administrative order. We may disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

 

Law Enforcement:
We may release your health information request by law enforcement official if 1) there is a court order, subpoena, warrant, summons or similar process; 2) if the request is limited to information needed to identify or locate a suspect, fugitive, material witness, or missing person; 3) the information is about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain your agreement; 4) the information is about a death that may be the result of criminal conduct; 5) the information is relevant to criminal conduct on our premises; and 6) it is needed in an emergency to report a crime, the location of a crime or victims, or the identity, description, or location of the person who may have committed the crime.

 

Coroners, Medical Examiners, and Funeral Directors:
We may release your health information to a coroner, medical examiner, or funeral director to identify a deceased person or cause of death, or other similar circumstance.

 

National Security and Intelligence Activities:
We may disclose your health information to authorized federal officials for intelligence and other national security activities authorized by law.

 

Inmates or Individuals in Custody.
If you are an inmate of a correctional institution or in custody we may disclose your information 1) for the institution to provide you with health care, 2) to protect your health and safety or that of others, and 3) for the safety and security of the institution.

 

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

 

Right to Inspect and Copy.
You have the right to inspect and copy your medical and billing records by written request to Chouchani Sayegh and Bagnarello MD LLP.

 

Right to Amend.
You have the right to request an amendment to your records by written request to Chouchani Sayegh and Bagnarello MD LLP.

 

Right to an Accounting Of Disclosures.
You have a right to an accounting of certain disclosures by written request to Chouchani Sayegh and Bagnarello MD LLP..
Right to Request Restrictions. You have the right to request restriction or limitation on your health information used for treatment, payment or health care operations. You may request us to limit disclosure to someone involved in your care or in payment for your care (such as a spouse) by written request to Chouchani Sayegh and Bagnarello MD LLP. We are not required to agree with your request, but we will try to comply.

 

Right to Request Confidential Communication.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. You can ask, for example, that we contact you only by mail or at work. Your written request must specify how or where you wish to be contacted and be addressed to Chouchani Sayegh and Bagnarello MD LLP.We will accommodate reasonable requests.

 

CHANGES TO THIS NOTICE
We may change this notice and make it effective for medical information we already have about you as well as new information. The current notice will be posted and available at all times. You have a right to request a paper copy of the current notice at any visit or by written request to Chouchani Sayegh and Baganrello MD LLP.

 

Lou Ann Philips ( Office Manager )
30 North Union Suite 101,
Williamsville, NY, 14221
Tel. 716-633-6363

Discrimination Law
Chouchani, Sayegh & Bagnarello, MD LLP complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Chouchani, Sayegh & Bagnarello, MD LLP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Chouchani, Sayegh & Bagnarello, MD LLP:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters.
  • Provides free language services to people whose primary language is not English, such as: Qualified interpreters at the Kenton Location, and/or information written in other languages if requested.

If you need these services, contact LouAnne Phillips, Office Manager.

If you believe that Chouchani, Sayegh & Bagnarello, MD LLP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

LouAnne Phillips, Office Manager
30 N. Union Road, Ste 101
Williamsville, NY 14221
716-633-6363

You can file a grievance in person or by mail or fax. If you need help filing a grievance, LouAnne Phillips, Office Manager is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Discrimination Law Taglines:
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