NOTICE
OF PRIVACY PRACTICES
As Required by the Privacy Regulations Created as a Result of
the Health Insurance Portability and Accountability Act of 1996
(HIPAA)
THIS
NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT
OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET
ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW THIS
NOTICE CAREFULLY.
A. OUR COMMITMENT TO
YOUR PRIVACY
Our practice is dedicated
to maintaining the privacy of your individually identifiable health
information (IIHI). In conducting our business, we will create
records regarding you and the treatment and services we provide
to you. We are required by law to maintain the confidentiality
of health information that identifies you. We also are required
by law to provide you with this notice of our legal duties and
the privacy practices that we maintain in our practice concerning
your IIHI. By federal and state law, we must follow the terms
of the notice of privacy practices that we have in effect at the
time.
We realize that these
laws are complicated, but we must provide you with the following
important information:
· How we may
use and disclose your IIHI
· Your privacy rights in your IIHI
· Our obligations concerning the use and disclosure of
your IIHI
The terms of this notice
apply to all records containing your IIHI that are created or
retained by our practice. We reserve the right to revise or amend
this Notice of Privacy Practices. Any revision or amendment to
this notice will be effective for all of your records that our
practice has created or maintained in the past, and for any of
your records that we may create or maintain in the future. Our
practice will post a copy of our current Notice in our offices
in a visible location at all times, and you may request a copy
of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS
ABOUT THIS NOTICE, PLEASE CONTACT:
Julie Major @ 877.584.5333
C. WE MAY USE AND DISCLOSE
YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE
FOLLOWING WAYS
The following categories
describe the different ways in which we may use and disclose your
IIHI.
- Treatment. Our
practice may use your IIHI to treat you. For example, we may
ask you to have laboratory tests (such as blood or urine tests),
and we may use the results to help us reach a diagnosis. We
might use your IIHI in order to write a prescription for you,
or we might disclose your IIHI to a pharmacy when we order a
prescription for you. Many of the people who work for our practice
– including, but not limited to, our doctors and nurses
– may use or disclose your IIHI in order to treat you
or to assist others in your treatment. Additionally, we may
disclose your IIHI to others who may assist in your care, such
as your spouse, children or parents.
Finally, we may also disclose your IIHI to other health care
providers for purposes related to your treatment.
- Payment. Our practice
may use and disclose your IIHI in order to bill and collect
payment for the services and items you may receive from us.
For example, we may contact your health insurer to certify that
you are eligible for benefits (and for what range of benefits),
and we may provide your insurer with details regarding your
treatment to determine if your insurer will cover, or pay for,
your treatment. We also may use and disclose your IIHI to obtain
payment from third parties that may be responsible for such
costs, such as family members. Also, we may use your IIHI to
bill you directly for services and items. We may disclose your
IIHI to other health care providers and entities to assist in
their billing and collection efforts.
- Health Care Operations.
Our practice may use and disclose your IIHI to operate our business.
As examples of the ways in which we may use and disclose your
information for our operations, our practice may use your IIHI
to evaluate the quality of care you received from us, or to
conduct cost-management and business planning activities for
our practice. We may disclose your IIHI to other health care
providers and entities to assist in their health care operations.
- Appointment Reminders.
Our practice may use and disclose your IIHI to contact you and
remind you of an appointment.
- Treatment Options.
Our practice may use and disclose your IIHI to inform you of
potential treatment options or alternatives.
- Health-Related Benefits
and Services. Our practice may use and disclose your IIHI to
inform you of health-related benefits or services that may be
of interest to you.
- Release of Information
to Family/Friends. Our practice may release your IIHI to a friend
or family member that is involved in your care, or who assists
in taking care of you. For example, a parent or guardian may
ask that a babysitter take their child to the pediatrician’s
office for treatment of a cold. In this example, the babysitter
may have access to this child’s medical information.
- Disclosures Required
By Law. Our practice will use and disclose your IIHI when we
are required to do so by federal, state or local law.
D. USE AND DISCLOSURE
OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories
describe unique scenarios in which we may use or disclose your
identifiable health information:
- Public Health Risks.
Our practice may disclose your IIHI to public health authorities
that are authorized by law to collect information for the purpose
of:
- maintaining vital
records, such as births and deaths
- reporting child
abuse or neglect
- preventing or
controlling disease, injury or disability
- notifying a person
regarding potential exposure to a communicable disease
- notifying a person
regarding a potential risk for spreading or contracting a
disease or condition
- reporting reactions
to drugs or problems with products or devices
- notifying individuals
if a product or device they may be using has been recalled
- notifying appropriate
government agency(ies) and authority(ies) regarding the potential
abuse or neglect of an adult patient (including domestic violence);
however, we will only disclose this information if the patient
agrees or we are required or authorized by law to disclose
this information
- notifying your
employer under limited circumstances related primarily to
workplace injury or illness or medical surveillance.
- Health Oversight
Activities. Our practice may disclose your IIHI to a health
oversight agency for activities authorized by law. Oversight
activities can include, for example, investigations, inspections,
audits, surveys, licensure and disciplinary actions; civil,
administrative, and criminal procedures or actions; or other
activities necessary for the government to monitor government
programs, compliance with civil rights laws and the health care
system in general.
- Lawsuits and Similar
Proceedings. Our practice may use and disclose your IIHI in
response to a court or administrative order, if you are involved
in a lawsuit or similar proceeding. We also may disclose your
IIHI in response to a discovery request, subpoena, or other
lawful process by another party involved in the dispute, but
only if we have made an effort to inform you of the request
or to obtain an order protecting the information the party has
requested.
- Law Enforcement.
We may release IIHI if asked to do so by a law enforcement official:
- Regarding a crime
victim in certain situations, if we are unable to obtain the
person’s agreement
- Concerning a death
we believe has resulted from criminal conduct
- Regarding criminal
conduct at our office
- In response to
a warrant, summons, court order, subpoena or similar legal
process
- To identify/locate
a suspect, material witness, fugitive or missing person
- In an emergency,
to report a crime (including the location or victim(s) of
the crime, or the description, identity or location of the
perpetrator)
- Deceased Patients.
Our practice may release IIHI to a medical examiner or coroner
to identify a deceased individual or to identify the cause of
death. If necessary, we also may release information in order
for funeral directors to perform their jobs.
- Organ and Tissue
Donation. Our practice may release your IIHI to organizations
that handle organ, eye or tissue procurement or transplantation,
including organ donation banks, as necessary to facilitate organ
or tissue donation and transplantation if you are an organ donor.
- Research. Our practice
may use and disclose your IIHI for research purposes in certain
limited circumstances. We will obtain your written authorization
to use your IIHI for research purposes except when an Institutional
Review Board or Privacy Board has determined that the waiver
of your authorization satisfies the following: (i) the use or
disclosure involves no more than a minimal risk to your privacy
based on the following: (A) an adequate plan to protect the
identifiers from improper use and disclosure; (B) an adequate
plan to destroy the identifiers at the earliest opportunity
consistent with the research (unless there is a health or research
justification for retaining the identifiers or such retention
is otherwise required by law); and (C) adequate written assurances
that the PHI will not be re-used or disclosed to any other person
or entity (except as required by law) for authorized oversight
of the research study, or for other research for which the use
or disclosure would otherwise be permitted; (ii) the research
could not practicably be conducted without the waiver; and (iii)
the research could not practicably be conducted without access
to and use of the PHI.
- Serious Threats
to Health or Safety. Our practice may use and disclose your
IIHI when necessary to reduce or prevent a serious threat to
your health and safety or the health and safety of another individual
or the public. Under these circumstances, we will only make
disclosures to a person or organization able to help prevent
the threat.
- Military. Our practice
may disclose your IIHI if you are a member of U.S. or foreign
military forces (including veterans) and if required by the
appropriate authorities.
- National Security.
Our practice may disclose your IIHI to federal officials for
intelligence and national security activities authorized by
law. We also may disclose your IIHI to federal officials in
order to protect the President, other officials or foreign heads
of state, or to conduct investigations.
- Inmates. Our practice
may disclose your IIHI to correctional institutions or law enforcement
officials if you are an inmate or under the custody of a law
enforcement official. Disclosure for these purposes would be
necessary: (a) for the institution to provide health care services
to you, (b) for the safety and security of the institution,
and/or (c) to protect your health and safety or the health and
safety of other individuals.
- Workers’ Compensation.
Our practice may release your IIHI for workers’ compensation
and similar programs.
E. YOUR RIGHTS REGARDING
YOUR IIHI
You have the following
rights regarding the IIHI that we maintain about you:
- Confidential Communications.
You have the right to request that our practice communicate
with you about your health and related issues in a particular
manner or at a certain location. For instance, you may ask that
we contact you at home, rather than work. In order to request
a type of confidential communication, you must make a written
request to Julie Major @ 877.584.5333 specifying the requested
method of contact, or the location where you wish to be contacted.
Our practice will accommodate reasonable requests. You do not
need to give a reason for your request.
- Requesting Restrictions.
You have the right to request a restriction in our use or disclosure
of your IIHI for treatment, payment or health care operations.
Additionally, you have the right to request that we restrict
our disclosure of your IIHI to only certain individuals involved
in your care or the payment for your care, such as family members
and friends. We are not required to agree to your request; however,
if we do agree, we are bound by our agreement except when otherwise
required by law, in emergencies, or when the information is
necessary to treat you. In order to request a restriction in
our use or disclosure of your IIHI, you must make your request
in writing to Julie Major @ 877.584.5333 Your request must describe
in a clear and concise fashion:
- (a) the information
you wish restricted;
- (b) whether you
are requesting to limit our practice’s use, disclosure
or both; and
- (c) to whom you
want the limits to apply.
- Inspection and Copies.
You have the right to inspect and obtain a copy of the IIHI
that may be used to make decisions about you, including patient
medical records and billing records, but not including psychotherapy
notes. You must submit your request in writing to Julie Major
@ 877.584.5333 in order to inspect and/or obtain a copy of your
IIHI. Our practice may charge a fee for the costs of copying,
mailing, labor and supplies associated with your request. Our
practice may deny your request to inspect and/or copy in certain
limited circumstances; however, you may request a review of
our denial. Another licensed health care professional chosen
by us will conduct reviews.
- Amendment. You may
ask us to amend your health information if you believe it is
incorrect or incomplete, and you may request an amendment for
as long as the information is kept by or for our practice. To
request an amendment, your request must be made in writing and
submitted to Julie Major @ 877.584.5333. You must provide us
with a reason that supports your request for amendment. Our
practice will deny your request if you fail to submit your request
(and the reason supporting your request) in writing. Also, we
may deny your request if you ask us to amend information that
is in our opinion: (a) accurate and complete; (b) not part of
the IIHI kept by or for the practice; (c) not part of the IIHI
which you would be permitted to inspect and copy; or (d) not
created by our practice, unless the individual or entity that
created the information is not available to amend the information.
- Accounting of Disclosures.
All of our patients have the right to request an “accounting
of disclosures.” An “accounting of disclosures”
is a list of certain non-routine disclosures our practice has
made of your IIHI for non-treatment, non-payment or non-operations
purposes. Use of your IIHI as part of the routine patient care
in our practice is not required to be documented. For example,
the doctor sharing information with the nurse; or the billing
department using your information to file your insurance claim.
In order to obtain an accounting of disclosures, you must submit
your request in writing to Julie Major @ 877.584.5333. All requests
for an “accounting of disclosures” must state a
time period, which may not be longer than six (6) years from
the date of disclosure and may not include dates before April
14, 2003. The first list you request within a 12-month period
is free of charge, but our practice may charge you for additional
lists within the same 12-month period. Our practice will notify
you of the costs involved with additional requests, and you
may withdraw your request before you incur any costs.
- Right to a Paper
Copy of This Notice. You are entitled to receive a paper copy
of our notice of privacy practices. You may ask us to give you
a copy of this notice at any time. To obtain a paper copy of
this notice, contact Julie Major @ 877.584.5333.
- Right to File a
Complaint. If you believe your privacy rights have been violated,
you may file a complaint with our practice or with the Secretary
of the Department of Health and Human Services. To file a complaint
with our practice, contact Julie Major @ 877.584.5333. All complaints
must be submitted in writing. You will not be penalized for
filing a complaint.
- Right to Provide
an Authorization for Other Uses and Disclosures. Our practice
will obtain your written authorization for uses and disclosures
that are not identified by this notice or permitted by applicable
law. Any authorization you provide to us regarding the use and
disclosure of your IIHI may be revoked at any time in writing.
After you revoke your authorization, we will no longer use or
disclose your IIHI for the reasons described in the authorization.
Please note, we are required to retain records of your care.
Again, if you have
any questions regarding this notice or our health information
privacy policies, please contact Julie Major @ 877.584.5333
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