NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
“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.”
With your consent, this office is permitted by federal privacy laws to make uses and disclosures of your health information for the purpose of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnosis, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Staff members will respect each patient’s right to privacy. All patient information will be kept confidential and may be disclosed only as specifically provided in this policy.
EXAMPLES OF HOW YOUR HEALTH INFORMATION IS USED FOR TREATMENT PURPOSES:
A nurse/assistant obtains medical/treatment information from/about you and records this information in your chart/health record.
During the course of your treatment, the physician determines he/she will need to consult or refer you to another physician/health care provider. He/she will share your health care information with such a physician/health care provider.
AN EXAMPLE OF HOW YOUR HEALTH INFORMATION IS USED FOR PAYMENT PURPOSES:
We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding the medical care given. We will provide this information.
AN EXAMPLE OF HOW YOUR HEALTH INFORMATION IS USED FOR HEALTH CARE OPERATIONS:
The State Licensing Authority wants to review records to assure that we have acted consistent with the State Laws regarding your care. In doing so, the Authority wants to take a sampling, which includes review of your chart. At the Licensing Authority’s request, we will provide it with a copy of
OUR OFFICE MAY CONTACT YOU TO PROVIDE APPOINTMENT REMINDERS OR INFORMATION ABOUT TREATMENT ALTERNATIVES OR OTHER HEALTH-RELATED SERVICES (TEST RESULTS) THAT MAY BE OF INTEREST TO YOU. IF YOU ARE UNAVAILABLE, WE MAY LEAVE A MESSAGE ON A RECORDER OR WITH THE PERSON ANSWERING YOUR HOME PHONE.
YOUR HEALTH INFORMATION RIGHTS
The health record we maintain and billing records are the physical property of the office. The information in it, however, belongs to you. You have the right to:
Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request, however, we will comply with any request granted.
Obtain a paper copy of the “Notice of Privacy Practices for Protected Health Information” (Notice) by making a request of our office.
Request that you be allowed to inspect and request a copy of your health record and billing record. This request must be in writing using the form we provide to you upon request.
The right to request an amendment to protected health information. The right to receive an accounting of disclosures.
This office is required by law to maintain the privacy of protected health information and to provide a notice detailing its legal duties and practices regarding protected health information.
This office must comply with the terms of the current notice. We will notify you if we cannot accommodate a requested restriction or request.
We will accommodate your reasonable requests regarding methods to communicate health information with you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain.
If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.
TO REQUEST INFORMATION OR FILE A COMPLAINT
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the office manager.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint with our office by delivering the written complaint to the office manager.
You may also file a complaint by mailing it to the Secretary of Health & Human Services whose address is: 200 Independence Avenue SW, Washington, DC 20201. The toll free phone number is: 877-696-6775. We cannot and will not require you to waive the right to file a complaint with the Secretary of Health & Human Services (HHS) as a condition of receiving treatment from our office. We cannot and will not retaliate against you for filing a complaint with the Secretary.
If you have any questions about this please contact our office manager.
OTHER DISCLOSURES AND USES
Business Associates: We have business associates with whom we may share your protected health information. For example, when filing a claim electronically, the information regarding your charges, diagnosis and treatment is shared with the Clearinghouse. This information is required in order to process and pay the claim.
Notification: Unless you object, we may use or disclose your protected health information to notify, or assist in notifying a family member, personal representative, or other person responsible for your care, about your location and general condition.
Communication with Family: Using our best judgment, we may disclose to a family member, other relatives, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Disaster Relief: We may use and disclose your protected health information to assist in disaster relief efforts.
Funeral Directors/Coroners: We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
Organ Procurement Organizations: Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or to other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Marketing: We may contact you to provide you with appointment reminders, treatment alternatives, test results, or other health-related services.
Food & Drug Administration: We may disclose to the FDA your protected health information relating to adverse events with respect to product defects, product recalls, repairs, or replacements.
Worker Compensation: If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation
Public Health: As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Abuse and Neglect: We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
Correctional Institutions: If you are an inmate of a correctional institution, we may disclose to the institution or agents there of your protected health information necessary for your health and the health and safety of other individuals.
Law Enforcement: We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.
Health Oversight: Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
Judicial/Administrative Proceedings: We may disclose protected health information in the course of any judicial or administrative proceedings as allowed or required by law, with your consent, or as directed by a proper court order.
To avert a serious threat or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
For Specialized Governmental Functions: We may disclose your protected health information for specialized government functions as authorized by law, such as Armed Forces personnel, for national security purposes, or to public assistance program personnel.
Please, contact us if you have any questions.
Effective Date: April 14, 2003