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
Effective Date: July 2013
Our organization is committed to providing you with medical care that meets your
needs. An important aspect of our service commitment to you is the protection
and security of the protected health information that we obtain about you. We
gives us an opportunity to share with you our policies that protect your health
We are required by law to provide you with this notice. It will describe to you
what protected health information we collect about you and how that information
might be used.
The Type Of Protected Health Information That We May Obtain About You:
including your name, address, date of birth,
phone number(s), name of your employer, your spouse or other family
members, and emergency contact.
including your insurance carrier, the name of the
insured person, insurance identification numbers, and benefits and
including your health history, past illnesses or
injuries, family medical history, your social activities including use of
tobacco, alcohol, or drugs, family life and living situation, your current
and/or ongoing health problems, including medications, allergies, advised
treatment and outcomes of that treatment.
including your insurance carrier, your record of
charges, adjustments, and payments to our organization.
How We May Use and Disclose Protected Health Information About You:
We are not obligated to have your consent when using or disclosing
protected health information for the following purposes:
A. For Treatment:
We may use and disclose your health information to
provide, coordinate or manage your health care and any related services.
We may disclose information about you to doctors, nurses, technicians,
office staff or other personnel who are involved in taking care of you and
- If we schedule a test, therapy or surgery for you, we must provide information about you in order to complete the scheduling. This includes your name, demographic and insurance information and the reason for the test.
- Your doctor may share your medical information with another doctor who is also involved in your care so that both may have all the information to make the best treatment decisions for you.
- We may share information with a pharmacy so that they can fill or refill a prescription for you.
- We may share information about you with another provider who is on call in the absence of your provider.
B. For Payment:
We may use and disclose your information to obtain
payment for services you receive.
- We may use or disclose your information to determine eligibility for insurance or benefits.
- We may use the name of your insurance carrier and your identification numbers in order to file a claim for you
- We may disclose your information about your conditions or reasons for seeking care and the care that is provided to your insurance carrier so that they may process and pay your claim.
- We may disclose information about your conditions to your insurance carrier to seek approval as necessary for recommended tests and treatment.
- We may provide information about your services to a health care clearinghouse so that they may distribute a claim to your insurance carrier on our behalf.
- If we refer you to another facility or provider we may provide them with your insurance information to expedite your registration and assure that they are participants in your insurance plan.
C. For Health Care Operations:
We may use or disclose protected health
information about you in order to evaluate our care for you or to meet a
business need of the organization. These activities include quality
assessment activities, employee review activities, training medical
students, compliance audits by your insurance carrier, and conducting or
arranging for other business activities.
- We may use information about you to evaluate the performance of our staff in caring for you.
- We may use your information to evaluate our efficiency.
- We may use your information to evaluate and respond to a patient complaint.
- We may share your health information with medical students or medical residents who are learning to care for patients.
We may also use or disclose protected health information to our Business
Associates in the performance of health care operations. A Business
Associate is an entity or person engaged by this organization to perform a
business activity on behalf of the organization. Our Business Associates
are obligated by contract to protect health information they receive or
generate about you.
- We may provide information to our transcription service so that they can produce a written copy of your encounter in our office.
- We may provide information to our accountant in order to prepare our organization’s financial reports.
- We may share information with qualified consultants in order for them to provide business management advice.
D. Other Contact Situations:
- We may use your information to call and remind you of an appointment in our office.
- We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.
- We may tell you about health-related products or services that may be of interest to you.
E. Special Situations:
Emergencies: We may use or disclose protected health information in the
case of a medical emergency.
Required by Law: We may use or disclose your protected health
information if the disclosure is required by law.
We may disclose protected health information about you
for public health activities. These activities generally include the following:
- To prevent or control disease, injury or disability
- To report births or deaths
- To report child abuse or neglect
- To report reactions to medications or problems with products
- To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
- To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
We may disclose protected health information to health oversight agencies that oversee our activities. These activities may include audits, investigations and inspections and are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws. Lawsuits or Disputes:
If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. Subject to legal requirements, we may also disclose medical information about you in response to a subpoena. Law Enforcement:
We may disclose protected health information, so long as all applicable legal requirements are met, for law enforcement purposes. Coroners, Medical Directors and Funeral Directors:
We may disclose protected 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. We may also release information about patients to funeral directors as necessary to carry out their duties. Workers Compensation:
We may disclose medical information about you for programs that provide benefits for work-related injuries or illness. Military Activities, National Security and Intelligence Activities:
If you are 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 disclose protected health information about you. We may also disclose information about foreign military personnel to the appropriate foreign military authority. Organ and Tissue Donation:
If you are an organ or tissue donor, we may disclose protected health information to organizations that handle organ or tissue procurement when necessary to facilitate organ or tissue donation or transplantation. Inmates:
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. The release would be necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others; or 3) for the safety and security of the correctional institution. Serious Threats:
As permitted by applicable law and standards of ethical conduct, we may use or disclose protected health information if we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Information that is not personally identifiable:
We may use or disclose information about you in a way that does not personally identify you.
Protected Health Information Use and Disclosure That Requires an
Opportunity for You to Agree or Object
Family and Friends:
We may disclose your protected health information to your
family or friends or any other individual identified by you when they are involved
in your care or the payment of your care. We will only disclose the protected
health information directly relevant to their involvement in your care or payment.
If you are available, we will give you an opportunity to object to these disclosures,
and we will not make these disclosures if you object.
If you are not available, we will determine whether a disclosure to your family or
friends is in your best interest, and we will disclose only the protected health
information that is directly relevant to their involvement in your care.
Protected Health Information That Cannot Be Disclosed Without Your
- Psychotherapy Notes
- Uses and disclosures used for Marketing Purposes
- Uses and disclosures that involve sale of Protected Health Information.
Other uses and disclosures of your protected health information will be made
only with your written authorization, unless otherwise permitted or required by
law as described below.
You may revoke this authorization by notifying us in writing at any time.
Your Rights as a Patient:
- You have the right to inspect and copy your protected health
You may inspect and obtain a copy of your protected health information
maintained in our office. We may charge you for the cost of copying, mailing
or associated supplies.
Under federal law, however, you may not inspect or copy psychotherapy
notes or information compiled in reasonable anticipation of a civil, criminal or
administrative action or proceeding. Certain documents pertaining to
laboratory services are also exempt under federal law.
Under certain circumstances, we may not grant your request. If we deny your
request, then you may appeal our decision.
We require that requests to access your protected health information be
made in writing. You can arrange to do this through our Privacy Officer.
- You have the right to be notified if a breach occurs involving your
protected health information.
You will be notified by certified letter detailing the nature of the data that was
breached, the severity of the breach and the manner in which your PHI was
- You have the right to request a restriction of your protected health
You may ask us not to disclose your protected health information for
treatment, payment or health care operations. You may also request that any
part of your protected health information not be disclosed to friends and/or
family members involved in your care.
- You have the right to receive communications regarding fundraising
activities performed by our office.
You will have an opportunity to opt out of any fund raising activities that
involve financial remuneration and intentions to raise funds.
- You have the right to restrict disclosure of PHI to a health plan.
If you pay for a service in full and out of pocket, you have the right to request
that our practice not disclose any information about that service to the
In order to request a restriction, you must do so in writing. The request must
specifically state what information is restricted and to whom the restriction
applies. You may request a restriction form from our Privacy Officer.
- You have the right to request to receive confidential communications
from us by alternative means or at an alternative location.
You may request that we communicate with you in a certain way or at a
specific location. We will attempt to accommodate all reasonable requests.
Please contact our Privacy Officer to make this request in writing. Your
request must specify where or how the communication is to be directed.
- You have the right to request that we amend your protected health
If you believe that protected health information we have about you is incorrect
or incomplete, you may request an amendment to this information.
We may not grant your request if we determine that the protected health
information that is the subject of your request:
- was not created by our organization
- is not a part of your medical or billing records
- is information that you are not permitted to inspect or copy
- is already a complete and accurate record
Amendment requests must be made in writing and must include a reason for
requesting the amendment. If you wish to amend your record, you may
contact our Privacy Officer for a form.
- You have the right to receive an accounting of certain disclosures we
have made, if any, of your protected health information.
You have the right to receive an accounting of disclosures of protected health
information made by us to individuals or entities other than you, except for
- to carry out treatment, payment and health care operations as described above
- to persons involved in your care or for other notification purposes as provided by law
- for national security or intelligence purposes as provided by law
- to correctional institutions or law enforcement officials as provided by law
- that occurred prior to April 14, 2003
You are allowed one free disclosure per each twelve-month period. If you
wish additional disclosures within that twelve-month period, we may charge
you the cost of providing the disclosure list.
Your request for a disclosure accounting must be made in writing. Please
contact our Privacy Officer to obtain a form.
- You have the right to file a complaint.
If you believe that your privacy rights have been violated, you have a right to
file a complaint in the form of a written letter with our office and with the
Secretary of Health and Human Services without fear of retaliation.
A letter of complaint filed with this office should be sent to our Privacy Officer
at the address listed below.
- You have the right to request and receive a paper copy or an electronic
copy of this notice from our office.
Revisions to Our Privacy Notice:
We are required to abide by the terms of this Privacy Notice. We may change
the terms of our notice at any time. The new notice will be effective for all
protected health information that we maintain at that time. Upon your request,
we will provide you with any revised Privacy Notice. You may obtain this by
calling our office and requesting that a revised copy be sent to you in the mail,
email or by asking for one at the time of your next appointment.
If you have questions about this document, or have questions about privacy or
patient rights, please contact our Privacy Officer.
Privacy Officer Name: CINDY MARGHEIM and ALYSSA MELTON
Phone Number: (503) 257-3204