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Office Information: Privacy Notice
We know that your protected health information is personal. We are committed to protecting your information. So as to provide you with good care and to insure that we follow all legal requirements, we document (in a medical record) the care and services that we provide to you. This Notice applies to those records. CHANGES TO THIS NOTICEWe reserve the right to change the terms of this Notice of Privacy Practices and to make the new provisions effective for all protected health information we already have about you, as well as any protected health information we create or receive in the future. If we make any changes, we will:
WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU TO PROVIDE TREATMENT TO YOU, TO OBTAIN PAYMENT FOR SERVICES RENDERED TO YOU, AND FOR HEALTHCARE OPERATIONS. We may use and disclose your protected health information for purposes of healthcare treatment, payment and healthcare operations as described below. For Treatment: We may use and disclose your protected health information to provide you with medical treatment and services and to coordinate or manage your healthcare and related services. We may use and disclose your protected health information to doctors and nurses, as well as lab technicians, dieticians, physical therapists or other parties involved in your care, both within our organization and with other health care providers involved in your care. We may disclose information to people outside our practice who may be involved in your care, such as your family members, clergy or others who participate in your care. All information is recorded in your medical record, which is necessary for health care providers to determine what treatment you should receive. Healthcare providers will also record actions taken by them in the course of your treatment and note your reactions. We may also disclose your protected health information to providers or facilities who may be involved in your care after you leave our facility or our care. Examples of how we will disclose information for treatment may include sharing information about you with:
For Payment: We may use and disclose your protected health information so that we can bill and receive payment for the treatment and services you receive from us. For billing and payment purposes, we may disclose your protected health information to an insurance company or managed care company, Medicare, Medicaid, or any other third party payer. The information on the bill may contain information that identifies your diagnosis, treatment and supplies used in the course of treatment. We may inform an insurance company about treatment that we intend to provide to you so that we can obtain the appropriate approvals and/or to confirm coverage for your treatment. Examples of how we will disclose information for payment include:
In the process of using your protected health information in the course of treatment, payment and health care operations, we may make incidental disclosure. We will make reasonable steps to limit incidental disclosures. Practice-specific example: We may disclose information as it relates to health care operations when we:
OTHER USES AND DISCLOSURES WE MAY MAKE WITHOUT YOUR WRITTEN AUTHORIZATION: Under the Health Insurance Portability and Accountability Act Privacy Regulations, we may use and disclose your protected health information in which you do not have to give authorization or otherwise have an opportunity to agree or object. “Use” refers to our internal utilization of your protected health information. Specifically, “use” under the privacy regulations means: “…with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis or such information within an entity that maintains such information.” Disclosure refers to the provision of information by us to parties outside of our organization. Specifically, disclosure means: “…the release, transfer, provision of access to our divulging in any other manner, or information outside of the entity holding the information.” We may make the following uses and disclosures of your protected health information without obtaining a written authorization from you in situations such as: Those Required by Law: We may disclose your protected health information when required to do so by law. For example, when federal, state or local law or other judicial or administrative proceeding requires that we disclose information about you. Public Health Risk: We may disclose your protected health information for public health activities. For example, we may disclose protected health information about you if you have been exposed to a communicable disease or may otherwise be at risk of spreading a disease. Other examples may include reports about injuries or disability, reports or births and deaths, reports of child abuse and/or neglect, and reports regarding recall of products. Our Facility Directory: Unless you object, we may use and disclose certain limited information about you in our directory , (or on our “sign-in sheet), while you are in our practice. This information may include your name and your location within our practice, (such as a department). Our directory will not include specific medical information about you. We may disclose directory information to people who ask for you by name. Unless you object, we may disclose protected health information about you to a family member, relative, close personal friend, caregiver, neighbor or other person(s) you identify, including clergy, who are involved in your care. These disclosures are limited to information relevant to the person’s involvement in your care, or in payment for your care. Unless you object, we may disclose protected health information about you to a public or private agency, (like the American Red Cross) for disaster relief purposes. Even if you object, we may still share information about you, if necessary for the emergency circumstances. Reporting Victims of Abuse, Neglect or Domestic Violence: When authorized by law, or if you agree to the report, and if we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your protected health information to notify a government authority. Health Oversight Activities: When authorized by law, we may disclose your protected health in-formation to a health oversight agency for activities. A health oversight agency is a state or federal agency that oversees the health care system. Some of the activities may include, for example, audits, investigations, inspections and licensure. Judicial and Administrative Proceedings: We may disclose your protected health information in response to a law suit, dispute, court or administrative order. We also may disclose protected health information in response to a subpoena, discovery request, or other lawful process by another party involved in the action. We will make a reasonable effort to inform you about the request. Law Enforcement: We may disclose your protected health information for certain law enforcement purposes, including, but not limited to:
Coroners, Medical Examiners, Funeral Directors, Organ/Tissue Donation Organizations: We may release your protected health information to a coroner, medical examiner, and funeral director. If you are an organ donor, we may release your protected health information to an organization involved in the donation of cadaveric organs and tissue to enable them to carry out their lawful duties. We can release information about deceased patients to funeral directors as necessary in allowing them to carry out their duties. We may disclose protected health information about you to a coroner or medical examiner for the purposes of identifying you should die. Research: In some situations, your protected health information may be used for research purposes if an institutional review board has approved the research. The institutional review board must have established procedures to insure that your protected health information remains confidential. To Avert a Serious Threat to Health or Safety: We may use or disclose your protected health information to someone able to help lessen or prevent the threatened harm when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. The disclosure would only be to a person or entity that would be able to help prevent the threat. Military and Veterans: If you are a member of the armed forces, we may use and disclose your protected health information as required by military command authorities. We may also release medical information about you if you are a member of a foreign military, as required by the appropriate foreign military authority.National Security and Intelligence Activities Protective Services For the President and Others: We may disclosed protected health information to authorized federal officials conducting national security, counterintelligence and intelligence activities authorized by law. Protective Services for the President and Others: We may disclose your protected health information to authorized federal officials as needed, to provide protection to the President of the United States, other persons, or foreign heads of states, or to conduct certain special investigations. Inmates/Law Enforcement Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your protected health in formation to the correctional institution, or official, for certain purposes. This type of disclosure is necessary for the following reasons:
Workers’ Compensation: We may use or disclose your protected health information to comply with laws and regulations relating to workers’ compensation or similar programs established by law that provide benefits for work-related injuries and/or illnesses. Appointment Reminders: We may use or disclose protected health information to remind you about:
Treatment Alternatives and Health-Related Benefits and Services: We may use or disclose your protected health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you. This may include telling you about:
Business Associates:
ANY OTHER USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION REQUIRES YOUR WRITTEN AUTHORIZATION Under any circumstances other than those listed above, we will request that you provide us with a written authorization before we use and disclose your protected health information to anyone. If you sign an authorization allowing us to disclose protected health information about you in a specific situation, you can later revoke (cancel) your authorization in writing. If you cancel your authorization in writing, we will not disclose your protected health information about you after we receive your cancellation, except for disclosures, which were already being processed or made before we received your cancellation. YOUR RIGHTS REGARDING YOUR PROTTECTED HEALTH INFORMATION: You have the following rights regarding your protected health information that we maintain: The Right to Access Your Personal Protected Health Information: Upon written request, you have the right to inspect and obtain a copy of your medical/protected health information except under certain limited circumstances. Under state law, if we make a copy of your medical record, we will not charge you more than is permitted by the current rate allowed by state law for copies. We may also charge you a reasonable fee for x-rays, mailing and other supplies related to this request. You should submit your written request to access your health information to our Privacy Officer, who is listed in this Notice. We may deny your request to inspect or receive copies in certain limited circumstances. If you are denied access to your medical/protected health information, in some cases you will have the right to request a review of this denial. A licensed health care professional designated by us, and who did not participate in the original decision to deny access, will perform this review. The Right To Request Restrictions: You have the right to request that a restriction on the way we use or disclose your protected health information for treatment, payment or health care operations. Additionally, you can request that we limit the information we disclose about you to those individuals involved in your care or the payment of your services, such as a relative or friend. For example, you could request that we not use or disclose information about a procedure you had performed by one of our physicians. You should submit your written request to restrict your health information to our Privacy Office, who is listed in this Notice. You must tell us what information you want restricted., to whom you want the information restricted, and whether you want to limit our use, disclosure or both. However, we are not required to agree to such a restriction. If we do agree to the restriction, we will honor that restriction except in the event of an emergency and will only disclose the restricted information to the extent necessary for your emergency treatment. The Right to Request Confidential Communications: You have the right to request that we communicate with you concerning your health matters in a certain manner or at a certain location. For example, you can request that we contact you only at a certain phone number, or a specific address. You should submit your written request for Confidential Communications to our Privacy Officer, who is listed in this Notice. You must tell us how and where you want to be contacted. We will accommodate your reasonable requests, but may deny the request if you are unable to provide us with appropriate methods of contacting you. The Right to Request an Amendment: You have the right to request that we make amendments or modify your clinical, billing and other protected health information for as long as the information is kepy by us. Your request must be made in writing and must explain your reasons for the requested amendment. We may deny your request for amendment if the information:
If we deny your request for amendment, we will give you a written denial notice, including the reasons for the denial and explain to you that you have the right to submit a written statement disagreeing with the denial. Your letter of disagreement will be attached to your medical record. You should submit your written request for an amendment to our Privacy Officer, who is listed in this Notice. The Right to An Accounting of Disclosures: You have the right to request an accounting, (a report), of certain disclosures of your protected health information. You may ask for disclosures made up to six years before your request, (but not including disclosures made prior to April 14, 2003). This is a listing of disclosures made by us or by others on our behalf. We are not required to include disclosures:
You must submit your request for an accounting of disclosures in writing to the Privacy Officer, who is listed in this Notice. You must state that time period for which you would like the accounting. The accounting will include the disclosure date, the name, address, (if known) of the person or entity that received the information, a brief description, of the information disclosed; and a brief statement of the purpose of the disclosure. If you request a listing of disclosures more than once within a 12-month period, we will charge you a reasonable fee for the accounting. The first accounting, within a 12-month period, is provided to you at no charge. We will inform you of the costs involved in the event that you wish to withdraw your request. The Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting our office in writing or by phone. DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE AND HIV-RELATED INFORMATION: For uses and disclosures of your protected health information related to care for psychiatric conditions, substance abuse, or HIV-related information, special conditions may apply. For example, we generally may not disclose this specially protected information in response to a subpoena, warrant or other legal process unless you sign a special authorization or if a court orders the disclosure. A general release of your protected health information will not be sufficient for purposes of disclosing psychiatric, substance abuse or HIV-related information. 1.Psychiatric Information: We will not disclose records relating to a diagnosis or treatment of your mental condition between you and the psychiatrist without specific written authorization or as required or permitted by law. 2.HIV-related Information: HIV-related information will not be disclosed, except under limited circumstances set forth under state or federal law, without your specific written authorization. 3.Substance Abuse Treatment: If you are treated in a substance abuse program, information which could identify you as alcohol or drug-dependent will not be disclosed without your specific authorization except for purposes of treatment or payment or when specifically required or allowed under state or federal law. COMPLAINTS: If you believe that your privacy rights have been violated, you may file a complaint in writing to us or with the government:
Office of Civil Rights
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