In an effort to ensure timely and safe care for our patients, we’re pleased to announce the offering of Telemedicine at Bergen Ear, Nose & Throat Associates.



The office Bergen Ear, Nose, and Throat Associates and Brian Benson, M.D. is required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information.  Please sign this form to acknowledge receipt of the Notice.


  • Date Format: MM slash DD slash YYYY
  • At which of the following number(s) do we have permission to contact or leave messages for you regarding your appointments, medication, medical information, or financial information.
  • Other than your insurance carrier, whom may we talk to about your healthcare information?
  • I give permission to fax requested information to the following fax #
  • I acknowledge that I have received a copy of this office’s Notice of Privacy Practices and I have had an opportunity to review it.
  • Date Format: MM slash DD slash YYYY


If you have any questions about this Notice, please contact our Privacy Officer at the number listed at the end of this Notice.

Each time you visit a healthcare provider, 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-related information. This Notice applies to all the records of your care generated by your health care provider.

Our Responsibilities

Bergen Ear, Nose & Throat Associates and Brian Benson, M.D. are required by law to maintain the privacy of your health information and to provide you with a description of our legal duties and privacy practices regarding your health information. The current Notice will be posted in the main waiting area and at our website at  The notice will include the effective date. In addition, we will make our best effort to provide you with a copy of this notice that we request you acknowledge with your signature.  

We are required by law to abide by the terms of this Notice and notify you if we make changes to this Notice, which may be at any time. Changes to the Notice will apply to your medical information that we already maintain as well as new information received after the change occurs. If we change our Notice, it will be posted in the main waiting area and at our website at  You may also request that a revised Notice be sent to you in the mail or you may ask for one at your next appointment or appropriate visit. This Notice will also serve to advise you as to your rights about your medical information.

How We May Use and Disclose Medical Information About You

The following categories describe examples of the way we use and disclose medical information:

For Treatment: We may use medical information about you to provide, coordinate and manage your treatment or services. We may disclose medical information about you to other doctors, nurses, technicians (e.g. clinical laboratories or imaging companies), medical students, or other personnel who are involved in your care.  We may communicate your information either orally or in writing by mail or facsimile.

We may also provide a subsequent healthcare provider with copies of various reports that should assist him or her in treating you. For example, your medical information may be provided to a physician to whom you have been referred to ensure that the physician has appropriate information regarding your previous treatment and diagnosis.

For Payment: We may use and disclose medical information about 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 before it approves or pays for the health care services, we recommend for you 

For Health Care Operations: We may use or disclose, as needed, your health information to support our business activities. These activities may include, but are not limited to quality assessment activities, employee review activities, licensing, legal advice, accounting support, information systems support and conducting or arranging for other business activities.  In addition, we may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment by telephone or reminder card.

Business Associates: There are some services provided in our organization through contracts with business associates. Examples include transcription, billing collections, document shredding services, quality assurance, and information system/software support.   When these services are contracted, we may disclose your health information to our business associate so that they can perform the job that 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 to appropriately safeguard your information through a written contract.

Other Permitted and Required Uses and Disclosures That May Be Made with Your Consent, Authorization or Opportunity to Object

We also may use and disclose your health information as set forth below. You can agree or object to the use or disclosure of all or part of your health information in these instances. If you are not present or able to agree or object to the use or disclosure of the health information (such as in an emergency situation), then your clinician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the information that is relevant to your health care will be disclosed.

Individuals Involved in Your Care or Payment for Your Care:  Unless you object, we may release medical information about you to a friend or family member who is involved in your medical care or who helps to pay for your care. In addition, we 

may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Future Communications: We may communicate to you via newsletters, mailings or other means regarding treatment options, information on health-related benefits or services; to remind you that you have an appointment for medical care; or other community based initiatives or activities in which our facility is participating.  If you are not interested in receiving these materials, please contact our Privacy Officer.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object

We may use or disclose your health information in the following situations without your authorization or without providing you with an opportunity to object. These situations include:

As required by law: We may use and disclose health information to the following types of entities, including but not limited to:

  • Food and Drug Administration
  • Public Health or Legal Authorities charged with preventing or controlling disease, injury, or disability
  • Correctional Institutions
  • Workers Compensation Agents
  • Organ and Tissue Donation Organizations
  • Military Command Authorities
  • Health Oversight Agencies
  • Funeral Directors, Coroners and Medical Directors
  • National Security and Intelligence Agencies
  • Protective Services for the President and Others
  • Authority that receives reports on abuse and neglect

Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

State-Specific Requirements: Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs.

Your Health Information Rights

Although your health record is the physical property of Bergen Ear, Nose & Throat Associates or Brian Benson, M.D.  that compiled it, you have the right to: Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. We ask that you submit these requests in writing.  Usually, this includes medical and billing records, but does not include psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. 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. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.  Requests for access to and copies of your medical information must be submitted to Bergen Ear, Nose & Throat Associates or Brian Benson, M.D.  in writing. The practice may charge $15 for each records search and $1 per page, for copies of medical records

Amend: If you feel that medical information, we have about you is incorrect or incomplete, you may ask us to amend the information by submitting a request in writing. You have the right to request an amendment for as long as we keep the information. 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 our disclosures of medical information about you except for certain circumstances, including disclosures for treatment, payment, health care operations or where you specifically authorized a disclosure.  Bergen Ear, Nose & Throat Associates or Brian Benson, M.D.  will provide the first accounting to you in any 12-month period without charge.  The cost for subsequent requests for an accounting within the 12-month period will be $10.00.  We ask that you submit these requests in writing.

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. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure that you had.  We ask that you submit these requests in writing.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes.  We ask that you submit these requests in writing.

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. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.  

To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.


If you believe your privacy rights have been violated, you may file a complaint with us by calling (201) 489-6520 and asking for the Privacy Officer or by contacting the Secretary of the Federal Department of Health and Human Services. All complaints must be also submitted in writing.  You will not be penalized for filing a complaint.

Other Uses of Medical Information

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, in writing, 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. However, we are unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we provided to you.

Privacy Officer: Linda Siculietano

Telephone Number: (551) 228-7587   

Bergen Ear, Nose & Throat Associates Brian Benson, M.D.

20 Prospect Avenue, Suite 613 Hackensack, NJ 07601. (201) 489-6520

Health Insurance Portability 

and Accountability Act of 1996

Notice of Privacy Practices