Notice of Privacy Practices
Effective
September 25, 2013
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THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
The
Practice (the “Practice”), in accordance with the Health Insurance
Portability and Accountability Act (HIPAA) Privacy Rule, (the “Privacy
Rule”) and applicable state law, is committed to protecting the privacy of
your protected health information (“PHI”). PHI includes information about
your health condition and the care and treatment you receive from the Practice.
The Practice understands that information about your health is personal. This
Notice explains how your PHI may be used and disclosed to third parties. This
Notice also details your rights regarding your PHI. The Practice is required by
law to maintain the privacy of your PHI and to provide you with this Privacy
Notice detailing the Practice’s legal duties and practices with respect to
your PHI. The Practice is also required by law to abide by the terms of this
Notice.
HOW
THE PRACTICE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The Practice, in accordance with this Notice and without asking for your express
consent or authorization, may use and disclose your PHI for the purposes of:
For Treatment – We may use your PHI to provide you
with treatment. We may disclose your PHI to doctors, nurses, technicians,
clinicians, medical students, hospitals and other health facilities involved in
or consulting in your care. We may also disclose information about you to people
outside the practice, such as other health care providers involved in providing
treatment to you, and to people who may be involved in your care, such as family
members, clergy, or others we use to provide services that are part of your
care. If we refer you to another health care provider, we would, as part of the
referral process share PHI information about you. For example, if you were
referred to a specialist, we would contact the doctor’s office and provide
such information about you to them so that they could provide services to you.
For Payment – We may use and disclose your PHI
so we can be paid for the services we provide to you. For example, we may need
to give your insurance company information about the health care services we
provided to you so your insurance company will pay us for those services or
reimburse you for amounts you have paid. We also may need to provide your
insurance company or a government program, such as Medicare or Medicaid, with
information about your condition and the health care you need to receive prior
approval or to determine whether your plan will cover the services.
For Health Care Operations
– We may use and disclose your PHI for our own health care operations and the
operations of other individuals or organizations involved in providing your
care. This is necessary for us to operate and to make sure that our patients
receive quality health care. For example, we may use information about you to
review the services we provide and the performance of our employees in caring
for you.
OTHER
USE & DISCLOSURES THAT ARE REQUIRED OR PERMITTED BY LAW
The
Practice may also use and disclose your PHI without your consent or
authorization in the following instances:
Appointment Reminders -We may use and disclose your
PHI to remind you by telephone or mail about appointments you have with us,
annual exams, or to follow up on missed or cancelled appointments.
Individuals Involved in Your Care or Payment for
Your Care
– We may disclose to a family member, other relative, a close friend, or any
other person identified by you. Certain limited PHI that is directly related to
that person’s involvement with your care or payment for your care. We may use
or disclose your PHI to notify those persons of your location or general
condition. This includes in the event of your death unless you have specifically
instructed us otherwise. If you are
unable to specifically agree or object, we may use our best judgment when
communicating with your family and others.
Disaster Relief - We also may use or disclose your
PHI to an authorized public or private entity to assist in disaster relief
efforts. This will be done to coordinate information with those organizations in
notifying a family member, other relative, close friend or other individual of
your location and general condition.
De-identified Information
– The Practice may use and disclose health information that may be related to
your care but does not identify you and cannot be used to identify you.
Business Associate – The Practice may use and
disclose PHI to one or more of its business associates if the Practice obtains
satisfactory written assurance, in accordance with applicable law, that the
business associate will appropriately safeguard your PHI. A business associate
is an entity that assists the Practice in undertaking some essential function,
such as a billing company that assists the office in submitting claims for
payment to insurance companies.
Personal Representative
– The Practice may use and disclose PHI to a person who, under applicable law,
has the authority to represent you in making decisions related to your health
care.
Emergency Situations – The Practice may use and
disclose PHI for the purpose of obtaining or rendering emergency treatment to
you provided that the Practice attempts to obtain your Consent as soon as
possible: The Practice may also use and disclose PHI to a public or private
entity authorized by law or by its charter to assist in disaster relief efforts,
for the purpose of coordinating your care with such entities in an emergency
situation.
Public Health and Safety Activities
– The Practice may disclose your PHI about you for public health activities
and purposes. This includes reporting information to a public health authority
that is authorized by law to collect or receive the information. These
activities generally include:
·
To
prevent or control disease, injury or disability
·
To
report births or deaths
·
To
report child, elder, or dependent adult abuse or neglect
·
To
report reactions to medications or problems with products
·
To
notify people of recalls of products they may be using
·
To
notify a person who may have been exposed to a disease or at risk for
contracting or spreading a disease or condition.
Victims of Abuse, Neglect or Domestic Violence
– We may disclose your PHI to a government authority authorized by law to
receive reports of abuse, neglect, or domestic violence, if we believe an adult
or child is a victim of abuse, neglect, or domestic violence. This will occur to
the extent the disclosure is (a) required by law, (b) agreed to by you, (c)
authorized by law and we believe the disclosure is necessary to prevent serious
harm, or, (d) if you are incapacitated and certain other conditions are met, a
law enforcement or other public official represents that immediate enforcement
activity depends on the disclosure.
Health Oversight Activities
– We may disclose your PHI to a health oversight agency for activities
authorized by law, including audits, investigations, inspections, licensure or
disciplinary actions. These and similar types of activities are necessary for
appropriate oversight agencies to monitor the nation’s health care system,
government benefit programs, and for the enforcement of civil rights laws.
Judicial and Administrative Proceedings
– We may disclose your PHI in response to a court or administrative order. We
also may disclose information about you in response to a subpoena, discovery
request, or other legal process but only if efforts have been made to tell you
about the request or to obtain an order protecting the information to be
disclosed.
Disclosures for Law Enforcement Purposes
– We may disclose your PHI to law enforcement officials for these purposes:
·
As
required by law
·
In
response to a court, grand jury or administrative order, warrant or subpoena
·
To
identify or locate a suspect, fugitive, material witness or missing person
·
About
an actual or suspected victim of a crime if, under certain limited
circumstances, we are unable to obtain that person’s agreement
·
To
alert a potential victim or victims or intending harm (“duty to warn”)
·
To
alert law enforcement officials to a death if we suspect the death may have
resulted from criminal conduct
·
About
crimes that occur at our facilities
·
To
report a crime, a victim of a crime or a person who committed a crime in
emergency circumstances
To Avert Serious Threat to Health or Safety
– We will use and disclose your PHI when we have a “duty to report” under
state or federal law because we believe that it is necessary to prevent a
serious threat to your health and safety or the health and safety of the public
or another person. Any disclosure would be to help prevent a threat.
Coroners, Medical Examiners and Funeral Directors
– We may disclose your PHI to a coroner or medical examiner for purposes such
as identifying a deceased person and determining cause of death. We also may
disclose information to funeral directors so they can carry out their duties.
Organ, Eye or Tissue Donation
– To facilitate organ, eye or tissue donation and transplantation, we may
disclose your PHI to organizations that handle organ procurement, banking or
transplantation.
Workers Compensation – We may disclose your PHI to
the extent necessary to comply with worker’s compensation and similar laws
that provide benefits for work-related injuries or illness without regard to
fault.
Special Government Functions
– If you are a member of the armed forces, we may release your PHI as required
by military command authorities. We may also release information about foreign
military authority. We may disclose information about you to authorized federal
officials for intelligence, counter-intelligence and other national security
activities authorized by law.
Research – We may use and/or disclose your PHI for
research projects that are subject to a special review process.
If researchers are allowed access to information that information that
identifies who you are, we will ask for your permission.
Fundraising – We may contact you with respect to
fundraising campaigns. If you do not
wish to be contacted for fundraising campaigns, please notify our Privacy
Officer in writing.
AUTHORIZATION
The
following uses and/or disclosures specifically require your express written
permission:
Marketing
Purposes – We will not use or disclose your PHI for marketing purposes
for which we have accepted payment without your express written permission.
However, we may contact you with information about products, services or
treatment alternatives directly related to your treatment and care.
Uses
and/or disclosures other than those described in this Notice will be made only
with your written authorization. If
you do authorize a use and/or disclosure, you have the right to revoke that
authorization at any time by submitting a revocation in writing to our Privacy
Officer. However, revocation cannot
be retroactive and will only impact uses and/or disclosures after the date of
revocation.
YOUR
RIGHTS
Right to Revoke Authorization
– You have the right to revoke any Authorization or consent you have given to
the Practice, at any time. To request a revocation, you must submit a written
request to the Practice’s Privacy Officer.
Right to Request Restrictions
– You have the right to request that we restrict the uses or disclosures of
your information for treatment, payment or healthcare operations. You may also
request that we limit the information we share about you with a relative or
friend of yours. You also have the right to restrict disclosure of information
to your commercial health insurance plan regarding services or products that you
paid for in full, out-of-pocket and we will abide by that request unless we are
legally obligated to do so.
We
are not required to agree to any other requested restriction. If we agree, we
will follow your request unless the information is needed to a) give you
emergency treatment, b) report to the Department of Health and Human Services,
or c) the disclosure is described in the “Uses and Disclosures That Are
Required or Permitted by Law” section. To request a restriction, you must have
your request in writing to the Practice’s Privacy Officer. You must tell us:
a) what information you want to limit, b) whether you want to limit use or
disclosure or both and c) to whom you want the limits to apply. Either you or we
can terminate restrictions at a later date.
Right to Receive Confidential Communications
– You have the right to request that we communicate your PHI in a certain way
or at a certain place. For example, you can ask that we only contact you by mail
or at work.
If
you want to request confidential communications you must do so in writing to our
Practice’s Privacy Officer and explain how or where you can be contacted. You
do not need to give us a reason for your request. We will accommodate all
reasonable requests.
Right to Inspect and Copy
– You have the right to inspect and request copies of your information.
To
inspect or copy your information, you may either complete an Authorization to
Release/Obtain Information form or write a letter of request, stating the type
of information to be released, the date(s) of service being requested, the
purpose of the request, and whether you wish to review the record or receive
copies of the requested information in your preferred format.
We will abide by your request in the format you have requested, if we are
able to do so. If we cannot provide
your records to you in the requested format, we will attempt to provide them in
an alternative format that you agree to. You
may also request that your records be sent to another person that you have
designated in writing. Direct this
request to the Practice’s Privacy Officer. You may be charged a fee for the
cost of copying, mailing or other expenses related with your request.
We
may deny your request to inspect and copy information in a few limited
situations. If you request is denied, you may ask for our decision to be
reviewed. The Practice will choose a licensed health care professional to review
your request and the denial. The person conducting the review will not be the
person who denied your request. We will comply with the outcome of that review.
Right to Amend – If you feel that your PHI is
incorrect, you have the right to ask us to amend it, for as long as the
information is maintained by us. To request an amendment, you must submit your
request in writing to the Practice’s Privacy Officer. You must provide a
reason for the amendment.
We
may deny your request for an amendment if it is not in writing or does not
include a reason for wanting the amendment. We also may deny your request if the
information: a) was not created by us, unless the person or entity that created
the information is no longer available to amend the information, b) is not part
of the information maintained by the Practice, c) is not information that you
would be permitted to inspect and copy or d) is accurate and complete.
If
your request is granted the Practice will make the appropriate changes and
inform you and others, as needed or required. If we deny your request, we will
explain the denial in writing to you and explain any further steps you may wish
to take.
Right to an Accounting of Disclosures
– You have the right to request an accounting of disclosures. This is a list
of certain disclosures we have made regarding your PHI. To request an accounting
of disclosures, you must write to the Practice’s Privacy Officer. Your request
must state a time period for the disclosures. The time period may be for up to
six years prior to the date on which you request the list, but may not include
disclosures made before April 14, 2003.
There
is no charge for the first list we provide to you in any 12-month period. For
additional lists, we may charge you for the cost of providing the list. If there
will be a charge, we will notify you of the cost in advance. You may withdraw or
change your request to avoid or reduce the fee.
Certain
types of disclosures are not included in such an accounting. These include
disclosures made for treatment, payment or healthcare operations; disclosures
made to you or for our facility directory; disclosures made with your
authorization; disclosures for national security or intelligence purposes or to
correctional institutions or law enforcement officials in some circumstances.
Right to a Paper Copy of this Notice
– You have the right to receive a paper copy of this Notice of Privacy
Practices, even if you have agreed to receive this Notice electronically. You
may request a paper copy of this Notice at any time.
Right to File a Complaint
– You have the right to complain to the Practice or to the United States
Secretary of Health and Human Services (as provided by the Privacy Rule) if you
believe your privacy rights have been violated. To file a complaint with the
Practice, you must contact the Practice’s Privacy Officer. To file a complaint
with the United States Secretary of Health and Human Services, you may write to:
Office for Civil Rights, U.S. Department of Health and Human Services,
To
obtain more information about your privacy rights or if you have questions about
your privacy rights you may contact the Practice’s Privacy Officer as follows:
Name:
Jeffrey R. Cates
200
N 6th St.
We
encourage your feedback and we will not retaliate against you in any way for the
filing of a complaint. The Practice reserves the right to change this Notice and
make the revised Notice effective for all health information that we had at the
time, and any information we create or receive in the future. We will distribute
any revised Notice to you prior to implementation.
I
acknowledge receipt of a copy of this Notice, and my understanding and my
agreement to its terms.
Patient:
Date: