Notice of Privacy Practices

Effective date 4/1/2003

Each time you visit us, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, and treatment, a plan for future care or treatment and billing-related information.  This notice applies to all of the records of your care generated by this clinic. 

Our Responsibilities:

We are required to maintain the privacy of your health information and provide you a description of our privacy practices.  We will abide by the terms of this notice.

Uses and Disclosures:

How we may use and disclose Health Information about you.

The following categories describe examples of the way we use and disclose health information:

For Treatment:  We may use health information about you to provide you treatment or services. We may disclose health information about you to doctors, nurses, technicians, health students, or other hospital personnel who are involved in taking care of you.  For example: a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. 

We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you if you are referred from this clinic.

For Payment:  We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer.  For example, we may need to give your insurance company information about your visit so they will pay us or reimburse you for the treatment.  We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.

For Health Care Operations:  Members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it.  The results will then be used to continually improve the quality of care for all patients we serve.  For example, we may also combine health information about many patients to evaluate the need for new services or treatment.  We may disclose information to doctors, nurses, and students for education purposes.  And we may combine health information we have with that of other clinics to see where we can make improvements.  We may remove information that identifies you from this set of health information to protect your privacy.

We may also use and disclose health information:

·                     To business associates we have contracted with to perform the agreed upon service and billing for it;

·                     To remind you that you have an appointment for medical care;

·                     To assess your dissatisfaction with our services;

·                     To tell you about possible treatment alternatives;

·                     To tell you about health-related benefits or services;

·                     To contact you apart of fundraising efforts;

·                     To inform Funeral Directors consistent with applicable law;

·                     For population based activities relating to improving health or reducing healthcare costs;

·                     For conducting training programs or reviewing competence of healthcare professionals;

·                     When disclosing information, primary appointment reminders and billing/collections efforts. We may leave messages on your answering machine or voice mail.

Business Associates:  There are some services provided in our organization through contracts with business associates.  Examples include radiology, certain laboratory tests, and a copy service we use when making copies of your health record.  When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we've asked them to do and bill you, your insurance company or a third-party payer for services rendered.  To protect your health information, however, we require the business associate to appropriately safeguard your information.

Individuals Involved in Your Care or Payment for Your Care:  We may release health information about you to a friend or family member who is involved in your medical care or who helps pay for your care.

Future Communications We may communicate to you via newsletters, mail outs or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activates our facility is participating in.

Organized Health Care Arrangement:  this faculty and its medical staff member have organized and are presenting you this document as a joint notice.  Information will be shared as necessary to carry out treatment, payment and healthcare operations.   Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time.

Affiliated Covered Entity:  Protected health information will be made available to hospital personnel at local affiliated hospitals as necessary to carry out treatment, payment and health care operations.  Caregivers at other facilities may have access to protected health information at their locations to assist in reviewing past treatment information as it may affect treatment at this time.  Please contact the Facility Privacy Official for further information on the specific sites included in this affiliated covered entity.

As required by law, we may also use the disclosed health information for the following types of entities, including but not limited to:

·                     Food and Drug Administration

·                     Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability

·                     Correctional Institutions

·                     Workers Compensation Agents

·                     Organ and Tissue Donation Organizations

·                     Military Command Authorities

·                     Health Oversight Agencies

·                     Funeral Directors, Coroners and Medical Directors

·                     National Security and Intelligence Agencies

·                     Protective Services for the President and Others

Law Enforcement/Legal Proceedings:  We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

State Specific Requirements:  Many states have requirements for reporting including population-based activities relating to improving health or reducing healthcare costs.  Some states have separate privacy laws that may apply additional legal requirements.   If the state privacy laws are more stringent than federal privacy laws, the state law preempts the federal law.

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the Right to:

·                     Inspect and Copy:  You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care.  Usually, this includes medical and billing records, but does not include psychotherapy notes.  We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to health information, you may request that the denial be reviewed.  Another licensed healthcare professional chosen by the clinic will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review.

·                     Amend : If you feel that health information we  have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the clinic.

·                     An Accounting of Disclosures:  You have the right to request an accounting of disclosures. This is a list of certain disclosures we make of your health information for purposes other than treatment, payment or healthcare operations where an authorization was not required.

·                     Request Restrictions : You have the right to request a restriction or limitation on health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.  WE ARE NOT REQUIRED TO AGREE TO YOUR REQUEST. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

·                     Request Confidential Communications: you have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example you can ask that we contact you at work instead of your home. The clinic will grant requests for confidential communications at alternative locations and/ or via alternative means only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by the clinic and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

·                     A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

               To exercise any of your rights, please obtain the required forms from the Privacy Official and submit your

               request in writing.

CHANGES TO THIS NOTICE

We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the clinic and include the effective date.  In addition, each time you register at the clinic for treatment or healthcare services, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the clinic by following the process outlined in the clinic’s Patient Rights documentation. You may also file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our record of the care that we provided to you and documented in the clinic.