NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION
(AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THAT INFORMATION.
PLEASE REVIEW THIS NOTICE
CAREFULLY.
__________________________________, herein referred to as “the Practice” is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about you, your medical condition, and the care and treatment you receive from the Practice. This Notice details how your PHI may be used and disclosed to third parties to carry out your treatment, payment for your treatment, health care operations of the Practice, and for other purposes permitted or required by law. This Notice also details your rights regarding your PHI.
1. The Practice may use and/or disclose your PHI for treatment, payment for your treatment, and health care operations of the Practice. The following are examples of the types of uses and/or disclosures of your PHI that may occur. These examples are not meant to include all possible types of use and/or disclosure.
(a) Treatment – In order to provide, coordinate and manage your health care, the Practice will provide your PHI to those health care professionals, whether on the Practice’s staff or not, directly involved in your care so that they may understand your medical condition and needs and possibly provide advice or treatment (e.g., a specialist or laboratory). For example: a physician treating your for a condition such as arthritis may need to know what medications have been prescribed for you by the physicians in this practice. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children, or parents.
(b) Payment – In order to get paid for services provided to you, the Practice will provide your PHI, directly or through a billing service, to appropriate third party payors, pursuant to their billing and payment requirements. For example: the Practice may need to provide your health insurance carrier or, if you are over 62, the Medicare program, with information about health care services that you received from the Practice so that the Practice can be properly reimbursed. The Practice may also need to tell your insurance plan about the need to hospitalize you so that the insurance plan can determine whether or not it will pay for the expense.
(c) Health Care Operations – In order for the Practice to operate in accordance with applicable law and insurance requirements and in order for the Practice to continue to provide quality and efficient care, it may be necessary for the Practice to compile, use and/or disclose your PHI. For example: the Practice may use your PHI in order to evaluate the performance of the Practice’s personnel in providing care to you, or to conduct cost-management and business planning activities for our practice.
1. The Practice may use and/or disclose your PHI, without a written Authorization from you, in the following instances:
(a) De-identified Information – When your PHI is altered so that it does not identify you and cannot be used to identify you.
(b) Business Associate – To a business associate, which is someone who the Practice contracts with to provide a service necessary for your treatment, payment for your treatment and health car operations (e.g., billing service or transcription service). The Practice will obtain satisfactory written assurance, in accordance with applicable law, that the business associates will appropriately safeguard your PHI.
(c)
Personal Representative – To a
person who, under applicable law, has the authority to represent you in making
decisions related to your health care.
(d)
Public Health Activities – To a
public health authority, as authorized by law, that collect information for the
purpose of: (1) maintaining vital records, such as
births and deaths; (2) reporting child abuse or neglect; (3) preventing or
controlling disease, injury or disability; (4) notifying a person regarding
potential exposure to a communicable disease; (5) notifying a person regarding
a potential risk for spreading or contracting a disease or condition; (6)
reporting reactions to drugs or problems with products or devices; (7)
notifying individuals if a product or device they may be using has been
recalled; (8) notifying appropriate government agency(ies) and authority(ies)
regarding the potential abuse or neglect of an adult patient (including
domestic violence); however, we will only disclose this information if the
patient agrees or we are required or authorized by law to disclose this
information; and, (9) notifying your employer under limited circumstances
related primarily to work-place injury or illness or medical surveillance.
(e) Federal Drug Administration - If required by the Food and Drug Administration to report adverse events, product defects or problems or biological product deviations, or to track products, or to enable product recalls, repairs replacements, or to conduct post marketing surveillance.
(f)
Abuse, Neglect or Domestic Violence
– To a government authority if the Practice is required by law to make such
disclosures. If the Practice is
authorized by law to make such a disclosure, it will do so if it believes that
the disclosure is necessary to prevent serious harm or if the Practice believes
that you have been the victim of abuse, neglect or domestic violence. Any such
disclosures will be made in accordance with the requirements of law, which may
also involve notice to you of the disclosure.
(g)
Health Oversight Activities – Such
activities, which must be required by law, involve government agencies involved
in oversight activities that relate to the health care system, government
benefit programs, government regulatory programs and civil rights law. Those activities include, for example,
criminal investigations, audits, disciplinary actions, or general oversight
activities relating to the community’s health care system.
(h)
Judicial and Administrative Proceeding
– As required in response to a court order or a lawfully issued subpoena.
(i)
Law Enforcement Purposes – In
certain instances, your PHI may have to be disclosed to a law enforcement
official for law enforcement purposes. Law enforcement purposes include: (1)
complying with a legal process (i.e. subpoena) or as required by law; (2)
information for identification and location purposes (e.g., suspect or missing
person); (3) information regarding a person who is or is suspected to be a
crime victim; (4) in situations where the death of an individual may have
resulted from criminal conduct; (5) in the event of a crime occurring on the
premises of the Practice; and (6) a medical emergency (not on the Practice’s
premises) has occurred, and it appears that a crime has occurred.
(j)
Coroner or Medical Examiner – To a
coroner or medical examiner for the purpose of identifying you or determining
your cause of death, or to a funeral director as permitted by law and necessary
to carry out its duties.
(k)
Organ, Eye or Tissue Donation – If
you are an organ donor, the Practice may disclose your PHI to the entity to
whom you have agreed to donate your organs.
(l)
Research – If the Practice is
involved in research activities, your PHI may be used, but such use is subject
to numerous governmental requirements intended to protect the privacy of your
PHI such as approval of the research by an institutional review board and
requirement that protocols must be followed (including an Authorization from
you).
(m)
Avert a Threat to Health or Safety
– If the Practice believes that disclosure is necessary to prevent or lesson a
serious and imminent threat to the health or safety of a person or the public
and the disclosure is to an individual who is reasonably able to prevent or
lessen the threat.
(n)
Specialized Government Functions –
When the appropriate conditions apply, the Practice may use PHI of individuals
who are Armed Forces personnel: (1) for activities deemed necessary by
appropriate military command authorities; (2) for the purpose of a
determination by the Department of Veteran Affairs of eligibility for benefits;
or (3) to a foreign military authority if you are a member of that foreign
military service. The Practice may also
disclose your PHI to authorized federal officials for conducting national
security and intelligence activities including the provision for protective
services to the President or others legally authorized.
(o)
Inmates – To a correctional
institution or a law enforcement official if you are an inmate of that
correctional facility and your PHI is necessary to provide care and treatment
to you or is necessary for the health and safety of other individuals or
inmates.
(p)
Workers’ Compensation – If you are
involved in a Workers’ Compensation claim the Practice may be required to
disclose your PHI to an individual or entity that is part of the Workers’
Compensation system.
(q)
Required by Law – If otherwise
required by law, but such use or disclosure will be made in compliance with the
law and limited to the requirements of the law.
Uses and/or disclosures, other than those described in this Notice, will be made by the Practice only with your written Authorization.
The Practice may use a sign-in-sheet at the registration desk. The Practice may also call your name in the waiting room when physician is ready to see you. The Practice will make efforts to minimize the identification, such as striking through sign-in sheet, identification once you are registered and using first names when calling your name in the waiting room.
The Practice may, from time to time, contact you to provide appointment reminders. The Practice may use multiple methods to remind you including telephone calls, secure e-mail messaging, and mail.
The Practice may, from time to time, contact you about treatment alternatives, or other health benefits or services that may be of interest to you.
The Practice does not use and/or disclose your PHI for marketing activities.
In order to provide on-call coverage for you, it is necessary that the Practice establish relationships with other Physicians who will take your call if a physician from the Practice is not available. Those on-call physicians will provide the Practice with whatever PHI that they create and will, by agreement, keep your PHI confidential.
The Practice may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person’s involvement with your care or the payment for your care. The Practice may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or health. However, in both cases, the following conditions will apply:
(a) If you are present at or prior to the use or disclosure of your PHI, the Practice may use or disclose your PHI if you agree, or if the Practice provides you with opportunity to object and you do not object, or if the Practice can reasonably infer from the circumstances, based on the exercise of its professional judgment, that you do not object to the use or disclosure.
(b) If you are not present, the Practice will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person’s involvement with your care.
FACILITY DIRECTORY [See Regs § 164.510(a)]
1. You have the right to:
(a) Revoke any Authorization, in writing, at any time. To request a revocation, you must submit a written request to the Practice’s Privacy Officer. After you revoke your authorizations we will no longer use or disclose your IIHI for the reasons described in the authorization. Note: We are required by law to retain records of your care.
(b) Request restrictions on certain use and/or disclosure or your PHI as provided by law. However, the Practice is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Practice’s Privacy Officer. In your written request, you must inform the Practice of what information you want to limit, whether you want to limit the Practice’s use or disclosure, or both, and to whom you want the limits to apply. If the Practice agrees to your request, the Practice will comply with your request except when otherwise required by law or unless the information is needed in order to provide you with emergency treatment.
(c) Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to the Practice’s Privacy Officer. The Practice will try to accommodate all reasonable requests.
(d) Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written request to the Practice’s Privacy Officer. The Practice can charge you a fee for the cost of copying, mailing or other supplies associated with your request. The Practice will also offer to schedule an appointment with you to review your medical record. In certain situations that are defined by law the practice may deny your request to insect and/or copy your PHI; however, you may request a review of our denial as set forth more fully in the written denial notice.
(e) Amend your PHI as provided by law. To request an amendment, you must submit a written request to the Practice’s Privacy Officer. You must provide a reason that supports your request. The Practice may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by the Practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the Practice, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the Practice’s denial, you will have the right to submit a written statement of disagreement.
(f)
Receive an accounting of disclosures of your PHI as
provided by law. An “accounting of disclosures” is a list of certain non-routine
disclosures the practice has made of your PHI for non-treatment or operations
purposes. Use of your PHI as part of the routine patient care in our practice
is not required to be documented. To request an accounting, you must
submit a written request to the Practice’s Privacy Officer. The request must state a time period, which
may not be longer than six (6) years and may not include dates before
(g) Receive a paper copy of this Privacy Notice from the Practice upon request to the Practice’s Privacy Officer.
(h) Complain to the Practice or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. To file a complaint with the Practice, you must contact the Practice’s Privacy Officer. All complaints must be in writing.
(i) To obtain more information on, or have your questions about your rights answered; you may contact the Practice’s Privacy Officer.
1. The Practice:
(a) Is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice of the Practice’s legal duties and privacy practices with respect to your PHI.
(b) Is required to abide by the terms of this Privacy Notice.
(c) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.
(d) Will not retaliate against you for making a complaint.
(e) Must make a good faith effort to obtain from you an acknowledgement of receipt of this Notice.
(f) Will post a copy of our current Notice in our offices in a visible location at all times.
This Notice is in effect as of __________________.
(month) (day), (year)
I acknowledge that I have received and/or reviewed a copy of this Notice.
__________________________________ ______________________________
Printed Name of Individual (Patient) Signature of Individual (Patient)
__________________________________ ______________________________
Signature of Personal
Representative Relationship
(e.g.,
Attorney-In-Fact,
Guardian, Custodial Parent if a minor)
Date Signed ______/______/______ Witness: ______________________