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Effective
July
1, 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.
Overview
Our office uses health information about you for treatment, to obtain
payment for treatment, for administrative purposes, and to evaluate the
quality of care that you receive. Your health information is contained in a
medical record that is the physical property of our practice.
The law requires us to maintain the privacy of your protected health
information (“PHI”) in accordance with this Notice of Privacy Practices
(“Notice”), as long as this Notice remains in effect. We are also required
to provide you with a copy of this Notice, which contains our privacy
practices, our legal duties, and your rights concerning your PHI.
From time to time, we may revise our privacy practices and the terms of our
Notice at any time, as permitted or required by applicable law. We
reserve the
right to apply a change in our policies to previously received PHI.
We will promptly revise and distribute our Notice whenever there is a
material change to the uses or disclosures, your individual rights, our
legal duties, or other privacy practices stated in this Notice. We will
mail a copy of the revised Notice to the address of record.
Our Privacy Practices
Use and Disclosure. We may use or disclose your PHI for treatment,
payment, or health care operations. For your convenience, we have provided
the following examples of such potential uses or disclosures:
Treatment.
Your PHI may be used to provide you with medical treatment for services.
For example, information obtained by a health care provider, such as a
physician, nurse, or other person providing health care services to you,
will record information in your record that is related to your treatment.
This information is necessary for health care providers to determine what
treatment you should receive.
Payment.
Your PHI may be used or disclosed in order to collect payment for the
medical services provided to you. For example, a bill may be sent to you or
a third-party payor, such as an insurance company or health plan. The
information on the bill may contain information that identifies you, your
diagnosis, and treatment or supplies used in the course of treatment.
Health Care Operations.
Your PHI may be used or disclosed as part of our internal health care
operations. Such health care operations may include, among other things,
quality of care audits of our staff and affiliates, conducting training
programs, accreditation, certification, licensing, or credentialing
activities.
Authorizations.
We will not use or disclose your medical information for any reason except
those described in this Notice, unless you provide us with a written
authorization to do so. We may request such an authorization to use or
disclose your PHI for any purpose, but you are not required to give us such
authorization as a condition of your treatment. Any written authorization
from you may be revoked by you in writing at any time, but such revocation
will not affect any prior authorized uses or disclosures.
Patient Access.
We will provide you with access to your PHI, as described below in the
Individual Rights section of this Notice. With your permission, or in some
emergencies, we may disclose your PHI to your family members, friends, or
other people to aid in your treatment or the collection of payment. A
disclosure of your PHI may also be made if we determine it is reasonably
necessary or in your best interests for such purposes as allowing a person
acting on your behalf to receive filled prescriptions, medical supplies, X
rays, etc.
Locating Responsible Parties.
Your PHI may be disclosed in order to locate, identify or notify a family
member, your personal representative, or other person responsible for your
care. If we determine in our reasonable professional judgment that you are
capable of doing so, you will be given the opportunity to consent to or to
prohibit or restrict the extent or recipients of such disclosure. If we
determine that you are unable to provide such consent, we will limit the PHI
disclosed to the minimum necessary.
Disasters.
We may use or disclose your PHI to any public or private entity authorized
by law or by its charter to assist in disaster relief efforts.
Required by Law.
We may use or disclose your medical information when we are required to do
so by law. For example, your PHI may be released when required by privacy
laws, work-related injuries or illness, public health laws, court or
administrative orders, subpoenas, certain discovery requests, or other laws,
regulations or legal processes. Under certain circumstances, we may make
limited disclosures of PHI directly to law enforcement officials or
correctional institutions regarding an inmate, lawful detainee, suspect,
fugitive, material witness, missing person, or a victim or suspected victim
of abuse, neglect, domestic violence or other crimes. We may disclose your
PHI to the extent reasonably necessary to avert a serious threat to your
health or safety or the health or safety of others. We may disclose your
PHI when necessary to assist law enforcement officials to capture a third
party who has admitted to a crime against you or who has escaped from lawful
custody.
Deceased Persons.
After your death, we may disclose your PHI to a coroner, medical examiner,
funeral director, or organ procurement organization in limited
circumstances.
Research.
Your PHI may also be used or disclosed for research purposes only in those
limited circumstances not requiring your written authorization, such as
those that have been approved by an institutional review board that has
established procedures for ensuring the privacy of your PHI.
Military and National Security.
We may disclose to military authorities the medical information of Armed
Forces personnel under certain circumstances. When required by law, we may
disclose your PHI for intelligence, counterintelligence, and other national
security activities.
Appointments.
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.
Your Individual
Rights
Access and Copies. In most cases, you have the right to review or to
purchase copies of your PHI by requesting access or copies in writing to our
Privacy Officer. Please contact our Privacy Officer regarding our copying
fees.
Disclosure Accounting.
You have the right to receive an accounting of the instances, if any, in
which your PHI was disclosed for purposes other than those described in the
following sections above: Use and Disclosures, Patient Access, and Locating
Responsible Parties. For each 12-month period, you have the right to
receive one free copy of an accounting certain details surrounding such
disclosures that occurred after
April 13, 2003.
If you request a disclosure accounting more than once in a 12-month period,
we will charge you a reasonable, cost-based fee for each additional
request. Please contact our Privacy Officer regarding these fees.
Additional Restrictions.
You have the right to request that we place additional restrictions on our
use or disclosure of your PHI, but we are not required to honor such a
request. We will be bound by such restrictions only if we agree to do so in
writing signed by our Privacy Officer.
Alternate Communications.
You have the right to request that we communicate with you about your PHI by
alternative means or in alternative locations. We will accommodate any
reasonable request if it specifies in writing the alternative means or
location, and provides a satisfactory explanation of how future payments
will be handled.
Amendments to PHI.
You have the right to request that we amend your PHI. Any such request must
be in writing and contain a detailed explanation for the requested
amendment. Under certain circumstances, we may deny your request but will
provide you a written explanation of the denial. You have the right to send
us a statement of disagreement to which we may prepare a rebuttal, a copy of
which will be provided to you at no cost. Please contact our Privacy
Officer with any further questions about amending your medical record.
Copy of Notice of Privacy Practices.
Should you obtain a copy of this Notice electronically, you may request a
paper copy of this Notice. Please contact our Privacy Officer and a copy
will be made available to you at no cost.
Our Obligations
We are required to:
·
maintain the privacy of protected health information;
·
provide you with this Notice of our legal duties and privacy practices with
respect to your health information;
·
abide by the terms of this Notice;
·
notify you if we are unable to agree to a requested restriction on how your
information is used or disclosed;
·
accommodate reasonable requests you may make to communicate health
information by alternative means or at alternative locations; and
·
obtain your written authorization to use or disclose your health information
for reasons other than those listed above and permitted under law.
Complaints
If you believe we have violated your privacy rights, you may complain to us
or to the Secretary of the U.S. Department of Health and Human Services.
You may file a complaint with us by notifying our Privacy Officer via our
main office.
We
support your right to protect the privacy of your medical information. We
will not retaliate in any way if you choose to file a complaint with us or
with the U.S. Department of Health and Human Services.
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