This notice describes the information privacy practices followed by our employees, staff, and other office personnel. The practices described in this notice will also be followed by health care providers you consult with by telephone (when your regular health care provider from our office is not available) who provide “call coverage” for your health care provider.
YOUR HEALTH INFORMATION This notice applies to the information and records we have about your health, health status, and the health care and services you receive at this office.
We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment We may use a sign-in sheet at the registration desk where you will be asked to indicate your name, date of birth, and physician. We may also call you by name in the waiting room when your physician is ready to see you.
We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students working with our physicians, office staff, or other personnel who are involved in taking care of you and your health.
Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care. Examples of such disclosures are phoning in prescriptions to your pharmacy, scheduling procedures, and coordinating treatment with other physicians to whom you have been referred. Family members and other health care providers may be part of your medical care outside this office and may require information about you that we have.
For Payment We may use and disclose health information about you so that the treatment and services you receive at this office may be billed may be billed to and payment maybe collected from you, and insurance company, or a third party. For example, we may need to give your health plan information about a service you received here so your health plan will pay us or reimburse you for the service. 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 obtain services from business associated such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such business associates as necessary to obtain these services.
Appointment Reminders We may contact you as a reminder that you have an appointment for treatment or medical care at the office. We may leave a reminder message on your home answering machine about an appointment.
Treatment Alternatives We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health Related Products and Services We may tell you about health-related products or services that may be of interest to you.
Please notify us if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services. If you advise us in writing (at the address listed on the back of this notice) that you do not wish to receive such communications, we will not use or disclose your information for these purposes.
SPECIAL SITUATIONS We may use and disclose health information about you without your permission for the following purposes, subject to all applicable legal requirement and limitations:
To Avert a Serious Threat to Health or Safety We may use and disclose health 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.
Required By Law We will disclose health information about you when required to do o by federal, state or local law.
Military, Veterans, National Security, and Intelligence If you are or were a member of the armed forces or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation We may release information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications, or problems with products.
Health Oversight Activities We may disclose health information to health oversight agencies for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies 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 disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.
Law Enforcement We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
Coroners, Medical Examiners, and Funeral Directors We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
Information Not Personally Identifiable We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Family and Friends We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment, which you would not object. For example, we may assume you agree to our disclosure of you personal health information to your spouse when you bring your spouse with you into the exam room during treatment.
In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. For example, we may inform the person who accompanied you to the emergency room that you suffered from a heart attack and provide updates on your progress and prognosis. We may also use our professional judgment and experience to make reasonable inferences that is in your best interest to allow another person to act on your behalf to pick up, for example, prescriptions or samples, medical supplies, X-rays, or medical records.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy You have the right to inspect and/or get a copy of your health information, such as medical and billing records, that we use to make decisions about your care. You must submit a written request to the Privacy Officer in order to inspect and/or get a copy of your health information. If you request a copy of the information, we may charge a fee of $25.00 for processing costs. We may deny your request to inspect and /or get a copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Right to Amend If you believe health 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 as long as the information is kept by this office.
To request an amendment, complete and submit a Medical Record Amendment/Correction form from the Privacy Officer. 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 as us to amend information that we did not create or for certain other reasons.
Right to an Accounting of Disclosures You have the right to request an “accounting of disclosures”. This list of the disclosures we made of protected health information about you that was not made for treatment, payment and health care operations. To request this list of accounting of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period which may not be longer than six (6) years and may not include dated before April 14, 2003. Your request should indicate in what form you want the list. The first list you request within a 12 month period will be free. For additional list, we may charge you for the costs 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. The right to receive this information is subject to certain exceptions, restrictions, and limitations.
Right to Request Restrictions You have the right to request in writing a restriction or limitation on the health 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 health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to these additional restrictions, but if we do agree, we will comply with our request except in the case of an emergency.
CHANGES TO THIS NOTICE We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.
QUESTIONS AND CONCERNS If you have any questions about this notice or if you believe your privacy rights have been violated, you may contact the Privacy Officer at 615-776-8088.