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THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND RELEASED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Who Will Follow This Notice ?
This notice describes our practice’s
privacy practices and that of:
- Any physician or health care professional authorized
to enter information into your medical chart.
- All areas of the practice
- All employees, staff, and other office personnel
- All these individuals, sites and locations follow the
terms of this notice. In
addition, these individuals, sites and locations
may share medical information with each other or with third
party medical specialists for treatment, payment, or office
operations purposes described in this notice
Our Pledge Regarding Medical Information:
We understand that medical information about
you and your health is personal. We are committed to protecting
medical information about you. We create a record of the
care and services you receive at our medical office. We need
this record to provide you with quality care and to comply
with certain legal requirements. This notice applies to all
of the records of your care generated by our office.
This notice will tell you about the ways
in which we may use and release medical information about
you. We also describe your rights and certain obligations
we have regarding the use and release of medical information.
We are required by law to:
- make sure that medical information that identifies you
is kept private
- give you this notice of our legal duties and privacy
practices with respect to medical information about you;
and
- follow the terms of this notice that is currently in
effect
How We May Use and Release Medical Information
About You ?
The following categories describe different
ways that we use and disclose medical information. Not every
use or release category will be listed. However, all of the
ways we are permitted to use and release information will
fall within one of the categories.
- For Treatment. We may use medical information
about you to provide you with medical treatment or services.
We may release medical information about you to the practice’s
office personnel who are involved in taking care of you
at the office or elsewhere. We also may release medical
information about you to people outside our office who
may be involved in your care after you leave the office,
such as family members or others we use to provide services
that are part of your care provided you have consented
to such release. These entities include third party physicians,
hospitals, nursing homes, pharmacies or clinical labs
with whom the office consults or makes referrals.
- For Payment. We may use and release
medical information about you so that the treatment and
services you receive at the medical office may be billed
to and payment may be collected from you, an insurance
company or a third party. For example, we may need to
give your health plan information about medical procedures
you received at the office so your health plan will pay
us or reimburse you for the services. We may also tell
your health plan about a treatment you are going to receive
to obtain prior approval or to determine whether your
plan will cover the treatment.
- For Health Care Operations. We may use
and release medical information about you for medical
office operations. These uses and releases are necessary
to run the medical office and make sure that all of our
patients receive quality care. For example, we may use
medical information to review our treatment and services
and to evaluate the performance of our staff in caring
for you. We may also combine medical information about
many medical office patients to decide what additional
services the office should offer, what services are not
needed, and whether certain new treatments are effective.
We may also release information to physicians, nurses,
and other office personnel for review and learning purposes.
- Appointment Reminders. We may use and
release medical information to contact you as a reminder
that you have an appointment for treatment or medical
care at the office.
- Treatment Alternatives. We may use and
release medical information to tell you about or recommend
possible treatment options or alternatives that may be
of interest to you.
- Health-Related Benefits and Services.
We may use and release medical information to tell you
about health-related benefits or services that may be
of interest to you.
- Individuals Involved In Your Care or Payment
for Your Care. We may release medical
information about you to a friend or family member who
is involved in your medical care provided you have consented
to such release. We may also give information to someone
who helps pay for your care. In addition, we may release
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.
- As Required By Law. We will disclose
medical information about you when required to do so by
federal, state or local law.
- To Avert a Serious Threat to Health or Safety.
We may use and release medical information about
you when necessary to prevent a serious threat to your
health and safety or the health and safety of the public
or another person. Any release, however, would only be
to someone able to prevent the threat.
Special Situations
- Health Oversight Activities. We may
release medical information to a health oversight agency
for activities authorized by law. These oversight activities
include, for example, audits, investigations, inspections,
and licensure. These activities are necessary 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 a dispute, we may release medical information
about you in response to a court or administrative order.
We may also release medical information about you 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.
- Coroners, Medical Examiners and Funeral Directors.
We may also release medical information to a coroner or
medical examiner. This may be necessary, for example,
to identify a deceased person or determine the cause of
death. We may also release medical information about
patients of the office to funeral directors as necessary
to carry out their duties.
Your Rights Regarding Medical Information
About You.
You have the following rights regarding
medical information we maintain about you:
- 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. To inspect
and copy medical information that may be used to make
decisions about you, you must submit your request in writing
to our office manager. If you request a copy of
the information, there will be a fee for the costs of
copying, mailing, or other office supplies associated
with your request. We may deny your request to inspect
and copy in certain very limited circumstances.
- Right to Amend. If you feel that medical
information we have about you is incorrect or incomplete,
you may ask us to amend the information. You have the
right to request an amendment for as long as the information
is kept by or for the medical office. To request an amendment,
your request must be made in writing and submitted to
the office manager. In addition, you must provide a reason
that supports your request. We may deny your request
for an amendment if it is not in writing or does not include
a reason to support the request. In addition, we may
deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity
that created the
- information is no longer available to make the amendment;
- Is not part of the medical information kept by or
for the medical office;
- Is not part of the information which you would be
permitted to inspect and copy; or
- Is accurate and complete
- Right to an Accounting of Disclosures.
You have the right to request an “accounting of
Disclosures.” This is a list of the releases we
made of medical information about you.
To request this list of disclosures, you
must submit your request in writing to our medical records
department. Your request must state a time period which may
not be longer than six years and may not include dates before
4-13-03. Your request should indicate in what form
you want the list (for example, on paper, electronically).
The first list you request within a 12 month period will be
free. For additional lists, we may charge you for the cost
of providing the list. We will notify you of the cost involved
and you may choose to withdraw or modify your request at that
time before any costs are incurred.
Right to Request Restrictions.
You have the right to request a restriction or limitation
on the medical information we use or release about you for
treatment, payment or health care operations. You also have
the right to request a limit on the medical information we
release 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 release information
about a surgery you had.
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 emergency
treatment.
To request restrictions, you must make your
request in writing to our office. In your request, you must
tell us (1) what information you want to limit; (2) whether
you want to limit our use, release or both; and (3) to whom
you want the limits to apply, for example, releases to your
spouse.
- Right to 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. For example, you can ask that we
only contact you at work or by mail. To request confidential
communications, you must make your request in writing
to the office manager. We will not ask you the reason
for your request. We will accommodate all reasonable
requests. Your request must specify how or where you
wish to be contacted.
- Right to 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 obtain a paper copy of this notice, you may request
a copy from our front office staff.
Changes To This Notice
·
We reserve the right to change this notice. We reserve the
right to make the revised or changed notice effective for
medical information we already have about you as well as any
information we receive the future. We will post a copy of
the current notice in the office. The notice will contain
on the first page, in the top left hand corner, the effective
date. In addition, each time you register we will offer you
a copy of the current notice in effect.
Complaints
If you believe you privacy rights have been
violated, you may file a complaint with the office or with
the Secretary of the Department of Health and Human Services.
To file a complaint with our practice, contact our practice
manager. All complaints must be submitted in writing.
You will not be penalized or retaliated
against for filing a complaint.
Other Uses Of Medical Information
Other uses and releases 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 release 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 release
medical information about you for the reasons covered by your
written authorization. You understand that we are unable
to take back any release we have already made with your permission,
and that we are required to retain our records of the care
that we provided to you.
If you have any questions about this notice,
please contact the practice manager. |
