Notice of Privacy Practices Effective: April 14, 2003
This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
We care about our patients’ privacy and strive to protect the confidentiality of your medical information at this practice. New federal legislation requires that we issue this official notice of our privacy practices. We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create paper and electronic medical records about your health, our care for you, and the services and/or items we provide to you as our patient. We need this record to provide for your care and to comply with certain legal requirements.
We are required by law to:
* make sure that the protected health information about you is kept private;
* provide you with a Notice of our Privacy Practices and your legal rights with respect to protected health information about you; and
* follow the conditions of the Notice that is currently in effect.
How We May Use and Disclose Medical Information About You
The following categories describe different ways that we use and disclose protected health information that we have and share with others. Not every use or disclosure in a category is listed.
Your Treatment: We use previously given medical information about you to provide you with current or prospective medical treatment or services. For example: a doctor to whom we refer you for ongoing or further care may need your medical record.
For Payment: We may use and disclose medical information about you so that the treatment and services you receive from us may be used and payment may be collected from you, an insurance company or a third party. Example: We may need to give your health care information, such as your name, address, office visit date, and codes identifying your diagnosis and treatment to your insurance company for payment.
Health Care Operations: We may use and disclose medical information about you for health care operations to assure that you receive quality care. Example: We may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you.
Other Uses or Disclosures That Can Be Made Without Consent or Authorization
* As required during an investigation by law enforcement agencies
* To avert a serious threat to public health or safety
* As required by military command authorities for their medical records
* To workers’ compensation or similar programs for processing of claims
* In response to a legal proceeding
* To a coroner or medical examiner for identification of a body
* If an inmate, to the correctional institution or law enforcement official
* As required by the US Food and Drug Administration (FDA)
* Other healthcare providers’ treatment activities
* Other covered entities’ and providers’ payment activities
* Other covered entities’ healthcare operations activities (to the extent permitted under HIPAA)
* Uses and disclosures in domestic violence or neglect situations
* Health oversight activities
* Other public health activities
We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.
Uses and Disclosures of Protected Health Information Requiring Your Written Authorization
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you give us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will thereafter no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care we have provided you.
Your Individual Rights Regarding Your Medical Information
Complaints: If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint.
Right to Request Restrictions: You have the right to request a restriction or limitation on the medical 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 medical information we disclose about you to someone who is involved in your care or the payment for your care (a family member or friend). For example, you could ask that we not use or disclose information about a particular treatment you received.
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, that we not leave voice mail or e-mail, or the like.
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. This includes your own medical and billing records, but does not include psychotherapy notes. Upon proof of an appropriate legal relationship, records of others related to you under your care (guardian or custodial) may also be disclosed. To inspect and copy your medical record(s), you must submit your request in writing to our Compliance Office. Ask the front desk person for the name of the Compliance Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies (tapes, disks, etc.) associated with your request.
Right to Amend: If you feel that the medical information we have about you in your records is incorrect or incomplete, then you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept. To request an amendment, your request must be made in writing and submitted to the Privacy Officer at this practice. 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 the information was not created by us, is not part of the medical information which you would be permitted to inspect and copy, or which we deem to be accurate and complete. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a coy of any such rebuttal. Statements of disagreement and any corresponding rebuttals will be kept on file and sent out with any future authorized requests for information pertaining to the appropriate portion of your record.
Right to an Accounting of Non-Standard Disclosures: You have the right to request a list of the disclosures we made of medical information about you. To request this list, you must submit your request to the Privacy Officer at this practice. Your request must state the time period or which you want to receive a list of disclosures that is not longer than six years, and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (example: on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we reserve the right to charge you for the cost of providing the list.
Right to a Paper Copy of This Notice: You have a right to a paper 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. To obtain a paper copy of the current Notice, please request one in writing from the Privacy Officer at this practice.
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 in the future. We will post a copy of the current Notice, with the effective date in the upper right corner of the first page.