Notice of Privacy Practices

 

PURPOSE: This notice describes how medical information about you may be disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY.

This notice takes effect on April 14, 2003 and remains in effect until we replace it.

1. OUR PLEDGE REGARDING MEDICAL INFORMATION

Protected health information is information about you, including demographics that may identify you and that relates to your past, present or future physical or mental healthcare and related health care services. We are committed to protecting your information. We create a record of the care and services you receive at our facility. We keep this record to provide you with quality care to comply with legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also inform you of your rights and outline certain duties we have regarding the use and disclosure of medical information.

2. OUR LEGAL DUTY

Current Law Requires Us to:

  • Protect your health information.
  • Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
  • Abide by the terms of privacy practices now in effect.
We Have the Right to:

  • Change our privacy practices and the new terms of our notice effective for all medical information that we store, including information previously created or received before the changes.

  • Make the changes in our privacy practice and the new terms of our notice effective for all medical information that we store, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
  • Before we make any important change in our privacy practices, we will change this notice and make the new notice available upon request.

3. USE & DISCLOSURE OF YOUR MEDICAL INFORMATION

This section describes different ways that we use and disclose medical information. Following are different kinds of uses or disclosures and their meaning. Not every use or disclosure will be listed. However, we have listed examples of ways we are permitted to use and disclose medical information.

FOR TREATMENT: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. Example: We would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you when we have necessary permission from you to disclose your protected health information. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.


FOR PAYMENT: Your protected health information will be used and disclosed, as needed, to obtain payments for health care services. Example: You have surgery. We may need to give your health insurance plan information about surgery you received, so that your plan will pay us or repay you for any surgery that you paid for. We may also tell your health plan about a treatment you are going to receive to get approval or to determine if your plan will pay for treatment.


FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting accreditation, certificates, licenses and credentials we need to serve you. We will share your protected health information with third party “business associates” that performs various activities (e.g., billing services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information we will have a written contract that contains terms that will protect the privacy of your protected health information.

Additional uses & disclosures of protected health information are based upon your written authorization.


Other uses and disclosures of protected health information will only be made with your written authorization unless otherwise permitted or required by law. You may revoke this authorization in writing at any time. The exception to this revocation is that your physician has taken action in reliance on this authorization. In addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purposes.

Notification: Medical information to notify or help notify:

* a family member

* your personal representative

* another person responsible for your care

We will share information about your location, general condition or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medicinal supplies, x-ray or medical information for you.

Research in Limited Circumstances: We may disclose your protected health information in limited circumstances to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.


Coroner, Medical Examiner, Funeral Director: To help them carry out their duties, we may share the medical information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.


Other permitted and required disclosures that may be made with your consent, authorization or opportunity to object.


Communication Barriers: We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to use or disclose under the circumstances.


Other permitted and required disclosures that may be made without your consent, authorization or opportunity to object.


-State and Federal law requires us to report cases of neglect, abuse and other reasons requiring law enforcement, inmates

-Military Activity and National Security

-Special Government Functions including military and veterans requests

-Court Orders and Judicial & Administrative Proceedings

-Public Health Activities

-Workers Compensation

-Health Oversight Agencies

-Appointment Reminders

-Disaster Relief

4. YOUR PATIENT RIGHTS

You have the Right to: Inspect or get copies of your medical information. You may request that we provide copies in a format other than photocopies. We will use the format you request unless it is not practical for us to do so. You must make your request in writing. You may get the form to request access by contacting the Privacy Compliance Officer listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice.


If you request copies, we will charge you $1.00 for each page, and postage if you want the copies mailed to you.


You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
Request that we place additional restrictions on our use or disclosures of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).


Request to receive confidential communications from us by alternative means or to alternative locations. Your request must be made in writing to the contact person listed at the end of this notice.


Request that we amend your protected health information. In certain cases, we may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.


You have the right to refuse a copy of the Notice of Privacy Practices. Your treatment will not be conditioned on your refusal unless it is for the purpose of creating health information or research related treatment.

QUESTIONS AND COMPLAINTS
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, YOU MAY CONTACT THE PRIVACY COMPLIANCE OFFICER, (931) 967-5860.
Additionally, if you believe that your privacy rights have been violated, contact the Privacy Compliance Officer. You may also submit a written complaint to the U.S. Department of Health & Human Services. You can use the contact listed above to provide you with the appropriate DHHS address. We will not retaliate in any way if you choose to file a complaint.