| Patient
Health Information |
| Your physician
is permitted by federal privacy laws to make uses and disclosures
of your health information for purposes of treatment, payment,
and health care operations. Protected health information is
the information we create and obtain in providing our services
to you. Such information may include documenting your symptoms,
examination and test results, diagnosis, treatment, and applying
for future care or treatment. Your health information also includes
payment, billing, and insurance information. |
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| How
We Use Your Patient Health Information |
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We use health
information about your treatment, to obtain payment, and for
health care operations, including administrative purposes
and evaluation of the quality of care that you receive. Before
we can use the information for these purposes, we must obtain
your written consent. Your consent is included on a form that
you have been asked to sign.
This Notice gives
examples of how we will use or disclose your health information
for treatment, payment, and health care operations. The Notice
describes circumstances when we may have to use or disclose
the information even without your consent.
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Examples
of Uses of Your Health Information for
Treatment, Payment, and Health Care Operation Purposes are: |
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Treatment:
We will use and disclose your health information to provide
you with medical treatment or services. Nurses, physicians,
and other members of your treatment team will record information
in your record and use it to determine the most appropriate
course of care. We may also disclose the information to other
health care providers who are participating in your treatment,
to pharmacists who are filling your prescriptions, and to
family members who are helping with your care.
Payment:
We will use and disclose your health information for payment
purposes. For example, we submit requests for payment to your
health insurance company. The health insurance company or
business associate helping us obtain payment may request information
from us regarding your medical care. We will provide information
to them about you and the care you were given.
Health
Care Operations: We will use and disclose your health
information to conduct our standard internal operations, including
proper administration of records. We may obtain services from
business associates such as quality assessment, quality improvement,
outcome evaluation, protocol and clinical guidelines development,
credentialing, medical record review, legal services, and
insurance. We will share information about you with such business
associates as necessary to obtain these services.
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| Special
Uses |
| We may also use
your information to contact you with appointment reminders and
information about treatment alternatives or other health-related
services that may be of interest to you. |
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| Other
Uses and Disclosures |
| We may use and
disclose identifiable health information about you for other
reasons, even without your consent. Subject to certain requirements,
we are permitted by law to give out health information without
your consent for the following purposes: |
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Required
by Law: We may be required by law to report suspected
abuse or neglect, gunshot wounds, or similar injuries
and events. |
| • |
Health
Oversight : We may be required to disclose information
to assist in investigations and audits, eligibility for
government programs, and similar activities. |
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Public
Health Activities: As required by law, we may
disclose vital statistics, diseases, and information related
to recalls of dangerous products to public health authorities. |
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Law
Enforcement Purposes: Subject to certain restrictions,
we may disclose information required by law enforcement
officials. |
| • |
Judicial
and Administrative Proceedings: We may disclose
information in response to an appropriate subpoena or
court order. |
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Serious
Threat to Health or Safety: We may use or declare
information when necessary to prevent a serious threat
to your health and safety or the health and safety of
the public or another person. |
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Deaths:
We may report information regarding deaths to coroners,
medical examiners, and funeral directors. |
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Military
or Veterans: If you are a member of the armed
forces, we may release information as required by military
command authorities. |
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Workers
Compensation: We may release information about
you for workers compensation or similar programs providing
benefits for work-related injuries or illness. |
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Research:
We may use or declare information for approved medical
research or clinical trials. |
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| In all other situations,
we will ask for your written authorization before using or disclosing
and identifiable health information about you. If you choose
to sign an authorization to disclose information, you can later
revoke that authorization to stop any future uses and disclosures. |
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| Your
Health Information Rights |
| The health and
billing records we maintain are the physical property of the
practice. You have the following rights with respect to your
Protected Health Information. Please contact the number listed
below to obtain the appropriate form for exercising these rights.
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Request
Restrictions: You may request restrictions on
certain uses and disclosures of your health information.
We are not required to grant the request, but we will
comply with any request granted. |
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Confidential
Communications: You may ask us to communicate
with you confidentially by requesting that communication
of your health information be made by alternative means
or at an alternative locations by delivering the request
in writing to our office using the form we give you upon
request. |
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Inspect
and Obtain Copies: You have the right to view
or receive an accounting of disclosures of your health
information as required to be maintained by law by delivering
a written request to our office using the form we provide
to you upon request. An accounting will not include uses
of information for treatment, payment, operations, or
disclosures. There may be a small charge for the copies. |
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Amended
Information: If you believe the information in
your record is not correct, or if important information
is missing, you have the right to request that your health
care record be amended by delivering a written request
to our office using the form we provide to you upon request.
(The physician or other health care provider is not required
to make such amendments); you may file a statement of
disagreement if your amendment is denied, and require
that the request for amendment and any denial be attached
in all future disclosures of your protected health information.
If you want to exercise any of the above rights, please
contact our Privacy Officer at the number listed, in person
or in writing, during normal office hours. She will provide
you with assistance on the steps to take to exercise your
rights. |
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| Our
Legal Responsibilities |
| This office
is required to: |
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Maintain
the privacy of your health information as required by
law; |
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Provide
you with a notice as to our duties and privacy practices
as to the information we collect and maintain about you;
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Abide
by the terms of the Notice; |
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Notify
you if we cannot accommodate a requested restriction or
request; and |
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Accommodate
your reasonable requests regarding methods to communicate
health information with you. |
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Accommodate
your request for an accounting of disclosures. |
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| Changes
in Privacy Practices |
| We reserve the
right to amend, change, or eliminate provisions in our privacy
practices and access practices and to enact new provisions regarding
the protected health information we maintain. If our information
practices change, we will amend our Notice. You are entitled
to receive a revised copy of the Notice by calling and requesting
a copy of our "Notice" or by visiting our office and
picking up a copy. For more information about privacy practices,
contact the number listed below. |
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| Complaints |
| If you are concerned
that we have violated your privacy rights, or if you disagree
with a decision we made about your records, you may contact
our office at the number listed below. You may also send a written
complaint to the US Department of Health and Human Services.
The proper person at the number listed below will provide you
with the appropriate address upon request. You will not be penalized
in any way for filing a complaint. |
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Effective
Date: April 14, 2003
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If
you have any question requests, or complaints, please contact
our office at (423) 246-6777
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