NOTICE OF PRIVACY PRACTICES AND RIGHTS. THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW THIS INFORMATION CAREFULLY. IT IS IMPORTANT TO US THAT YOU KNOW YOUR RIGHTS. OUR OBLIGATION UNDER THE FEDERAL LAW:
We are required by applicable federal law to maintain the privacy of your health information. This notice provides you with information on the Privacy Practices we have adopted to maintain the privacy of your health information and is effective as of the date noted above until we change the practices and notify you of some changes. We reserve the right to change our privacy practices. If we make a change, it will be in compliance with applicable laws that govern the protection of your privacy. You may request a copy of our privacy notice at any time. You have certain rights that are described in this notice. Please review it carefully and understand the rights that you have our policies that have been implemented to protect you rights and our obligations under applicable law. A privacy officer is named at the end of this notice. Please contact the privacy officer if you have further questions about our policies.
USE AND DISCLSOSURE-YOUR PROTECTED HEALTH INFORMATION AND OUR POLICIES:
We use and disclose health information about you to other treatment providers for treatment purposes, for payment purposes and for healthcare operations.
We use your information and we may disclose your information to other healthcare providers that provide treatment to you.
We may use your information for payment purposes so we may receive payment for the services provided to you.
We may disclose and/or use health information for purposes of healthcare operations which can include audits by regulatory agencies and other authorized agencies, assessment activities of our business and how it operates, to maintain and manage our healthcare systems that are used in our business, to review the qualifications and competence of our employees or other healthcare providers, evaluating performance, for purpose of accreditation and certification, for training and for other healthcare operations that must be conducted in order for us to operate our business and provide healthcare for you.
AUTHORIZATION FOR USE OF HEALTHCARE INFORMATION:
In addition to the use of your information for purposes of treatment, payment and operations, we may also obtain your authorization to disclose your protected health information to others. If you give us written authorization to disclose your information, you may revoke that permission at any time, in writing, by delivering a copy of the revocation to us. The revocation is only effective after we have received it and does not apply to information disclosed pursuant to the authorization prior to our receiving your revocation notice. We will not disclose your protected health information, except for the reasons set forth in this notice and unless such disclosure is incidental or made pursuant to applicable federal and/or state law, unless we have your written authorization to do so. We may also discuss health information verbally with you in our office or facilities and will keep such discussions with you private. In the event others are present in our office or facility and may be able to hear our discussions, we will notify you before we begin talking with you about your health information and you will have the opportunity to have the discussion in a private room, office or other location.
If a family member of friend is present and we are discussing your health information with them, you understand that such discussions are made with your permission. We will ask you for your permission if such a situation exists.
PERSONS TREATING YOU OR PROVIDING CARE OR SERVICES FOR YOU:
Our office may use or disclose information to notify or assist in the location and/or notification of your family member, your personal representative or any other person responsible for your care and general condition. If you are present, then prior to the use or disclosure of your protected health information, you have the opportunity to object by telling us you do not want the information disclosed the third party. In the event of an emergency or your incapacity, we will disclose information based on our personal judgment. The information we disclose will be limited to that information directly related to your treatment in the particular circumstances. In any case, we will use our professional judgment and will follow our general policies and practices to make reasonable determinations with respect to allowing a person to pick-up prescriptions, medical supplies, x-rays or other similar forms of health related materials and/or information.
We will not use your health information for marketing communications without your written authorization unless the communication relates specifically to your treatment. When we believe materials may assist you in respect to your treatment, we may directly provide you with information about treatment options, including products and/or services that we believe, in our professional judgment, are important to you.
ABUSE, NEGLECT AND OTHER RELATED CIRCUMSTANCES:
We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence. We may also disclose the information to avert a serious health crisis that could affect you or the health or the safety of others.
LEGALLY REQUIRED TO DISCLOSE:
In certain circumstances, we may be required by law to disclose your protected health information.
We may also use or disclose your health information to provide you with appointment reminders including voicemail messages, letters or postcards.
We may disclose certain information for purposes of National Security. We may disclose this information to authorized federal authorities for lawful intelligence and other national security activities.
YOUR RIGHTS TO VIEW, COPY, AMEND, AND OTHERWISE ACCESS YOUR HEATH INFORMATION:
You have the right to look at or get copies of your protected health information, with some limited exceptions. You may ask us to provide photocopies or to provide your information in other formats. We will provide in a format other than photocopies when we reasonably and practically can do so. You must request that we provide this information to you in writing unless you are in our office and request it personally. We may seek further information from you to ensure that you are the actual person requesting the information and that it is not being requested by an unauthorized person. You should address your request to the contact officer name below. If you request copies, we will charge you $0.20 per page and $22.00 per hour for staff time to locate and copy your health information. You will also be charged for postage if you request that we send the information to you. You may also visit our office to view and copy your information. The same copying charges apply, however, if you visit personally and take delivery of your information, you will not be charged for postage. If you request that we provide the information in an alternative format that we can reasonably and practically accommodate, you will be charged for the time and materials required to prepare and deliver the information. Our policies provide for a reasonable period of time for us to comply with your request. You have the right to request that we place additional restrictions on how to protect your health information is used or disclosed. We may or may not agree to these restrictions. For your protection, you should provide these requests in writing to our office. If we do agree to the requests, we will notify you in writing of our agreement to the requests and will abide by them (except in emergency circumstances).
You also have the right to receive a list of instances in which we and our business associates disclosed you information for purposes, other than treatment, payment and healthcare operations and certain activities, for the last six (6) years. We will begin accounting for this information on
February 1st, 2005 and you will be able to receive the disclosure history, as described above, from that date forward. If you request this accounting more than once in a 12-month period, we will charge you a reasonable, cost based fee for responding to these additional requests. Our policies provide for a reasonable period of time for us to comply with your request.
You have the right to request that we amend your health information (your request must be in writing and if you must explain why you want the information amended). We may deny your request under certain circumstances. If you have received this notice electronically, you may request that we may provide you with a written copy. You are entitled to receive this notice in written form. You have the right to ask us to communicate with you in an alternative manner and in different locations. You must make your request in writing. Your request must specify the alternative manner and locations and must explain how your payments will be handled considering the requests.
COMPLAINTS AND QUESTIONS YOU MAY HAVE ABOUT THIS NOTICE AND THE RIGHTS DESCRIBED HEREIN:
If you have additional questions or want more information about our privacy practices, you may contact the person designated below. This person is our privacy officer and can answer your questions about our policies and how they have been implemented in our office. We utilize an electronic management system to help us manage and safeguard your privacy. If you are concerned that we may have violated your privacy rights or if you disagree with a decision we made about access to your health information or in response to a request you have made based on your rights as explained in this notice you may complain to the person named below. You may also submit a written complaint to United States Department of
Health and Human Services. We will provide you with the address to use to file your complaint with the Department of Health and Human Services
upon request. We support your right to privacy as provided by the law. If you choose to complain, we will not retaliate in any manner.
PRIVACY OFFICER CONTACT INFORMATION:
1 (866) 205-2309