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Section - Patient Information
Notice of Privacy Practices
Effective June 26, 2012
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. "PLEASE REVIEW IT CAREFULLY".
If you have any questions about this notice, please ask to speak to our Privacy Officer or call our Privacy Officer at 908-685-1887 EXT. 247.
This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice of Privacy Practices describes how we may use or disclose your protected health information, with whom that information may be shared, and the safeguards we have in place to protect it. This notice also describes your rights to access and amend your protected health information. You have the right to approve or refuse the release of specific information outside of our Practice except when the release is required or authorized by law or regulation.
ACKNOWLEDGMENT OF AWARENESS OF THIS NOTICE
You will be asked to provide a signed acknowledgment of receipt of this notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care services will in no way be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide your treatment, and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.
OUR DUTIES TO YOU REGARDING PROTECTED HEALTH INFORMATION
"Protected health information" is individually identifiable health information. This information includes demographics (for example, age and address), and relates to your past, present, or future physical or mental health or conditions and related health care services.
Our Practice is required by law to do the following:
Keep your protected health information private
Give you this notice of our legal duties and privacy practices related to the use and disclosure of your protected health information
Follow the terms of the notice currently in effect
Communicate to you any changes we may make in the notice
We reserve the right to change this notice. Its effective date is at the top of the first page and at the bottom of the last page. We reserve the right to make the revised or changes notice effective for health information we already have about you as well as any information we receive in the future. You may request and receive a copy of the Notice of Privacy Practices.
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
Following are examples of permitted uses and disclosures of your protected health information. These examples are not exhaustive.
Required Uses and Disclosures
By law, we must disclose your health information to you unless it has been determined by a health care professional that it would be harmful to you. We must also disclose health information to the Secretary of the Department of Health and Human Services (DHHS) for investigations or determinations of our compliance with laws on the protection of your health information.
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 healthcare with a third party. For example, we may disclose your protected health information from time-to-time to another physician or health care provider (for example, a specialist, pharmacist, or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment. This includes pharmacists who may be provided information on other drugs you have been prescribed to identify potential interactions.
In emergencies, we will use and disclose your protected health information to provide the treatment you require.
Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities we may need to undertake before your health care insurer approves or pays for the health care services recommended for you, such as determining eligibility or coverage for benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a surgical procedure might require that your relevant protected health information be disclosed to obtain approval to perform the procedure at a particular facility.
Health Care Operations
We may use or disclose, as needed, your protected health information to support our daily activities related to providing health care. These activities include, but are not limited to billing, collection, quality assessment activities, investigations, oversight or staff performance reviews, licensing, communications about a product or service, and conducting or arranging for other health care related activities. For example, we may disclose your protected health information to a billing agency in order to prepare claims for reimbursement for the services we provide to you. We may call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, results of lab tests and discussions of your referrals. If we are unable to reach you directly we will leave a telephone message.
We will share your protected health information with other persons or entities that perform various activities (for example, a transcription service) for our Practice. These business associates of our Practice will also be required to protect your health information.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that might interest you. For example, your name and address may be used to send you a newsletter about our Practice and the services we offer. We may also send you information about products or services that we believe might benefit you.
Required by Law
We may use or disclose your protected health information if law or regulation requires the use or disclosure.
We may disclose your protected health information to a public health authority who is permitted by law to collect or receive the information. The disclosure may be necessary to do the following:
Prevent or control disease, injury, or disability
Report births and deaths
Report child abuse or neglect
Report reactions to medications or problems with products
Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence
We may disclose your protected health information, if authorized by law, to a person who might have been exposed to a communicable disease or might otherwise be at risk of contracting or spreading the disease or condition.
We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. These health oversight agencies might include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
Food and Drug Administration
We may disclose your protected health information to a person or company required by the Food and Drug Administration to do the following:
Report adverse events, product defects, or problems and biologic product deviations
Enable product recalls
Make repairs or replacements
Conduct post-marketing surveillance as required
We may disclose protected health information during any judicial or administrative proceeding, in response to a court order or administrative tribunal (if such a disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request, or other lawful process.
We may disclose protected health information for law enforcement purposes, including the following:
Responses to legal proceedings
Information requests for identifications and locations
Circumstances pertaining to victims of a crime
Deaths suspected from criminal conduct
Crimes occurring on our premises
Medical emergencies (not on our premises) believed to result from criminal conduct
Coroners, Funeral Directors, and Organ Donations
We may disclose protected health information to coroners or medical examiners for identification to determine the cause of death or for the performance of other duties authorized by law. We may also disclose protected health information to funeral directors as authorized by law. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donations.
We may disclose your protected health information to researchers when authorized by law, for example, if 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.
Under applicable Federal and state laws, we may disclose your protected health information if we believe that its 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. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security
When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities believed necessary by appropriate military command authorities to ensure the proper execution of the military mission including determination of fitness for duty; or (2) to a foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information to authorized Federal officials for conducting national security and intelligence activities including protective services to the President or others.
We may disclose your protected health information to comply with workers compensation laws and other similar legally established programs.
We may use or disclose your protected health information if you are an inmate of a correctional facility, and we created or received your protected health information while providing care to you. This disclosure would be necessary (1) for the institution to provide you with health care, (2) for your health and safety or the health and safety of others, or (3) for the safety and security of the correctional institution.
State laws concerning minors permit or require certain disclosure of protected health information to parents, guardians, and persons acting in a similar legal status. We will act consistently with the laws of this state (or, if you are treated by us in another state, the laws of that state) and will make disclosures following such laws.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION REQUIRING YOUR PERMISSION
In some circumstances, you have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. Following are examples in which your agreement or objection is required.
Individuals Involved in Your Health Care
Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. We may also give information to someone who helps pay for your care. Additionally we may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person who is responsible for your care, of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and coordinate uses and disclosures to family or other individuals involved in your health care.
Your Rights Regarding Your Health Information
You may exercise the following rights by submitting a written request to our Privacy Officer. Our Privacy Officer can guide you in pursuing these options. Please be aware that our Practice may deny your request; however, you may seek a review of the denial.
You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. A designated record set contains medical and billing records and any other records that our Practices uses for making decisions about you. Copies may be obtained at your expense.
Right to Inspect and Copy
This right does not include inspection and coping of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information.
Right to Request Restrictions
You may ask us not to use or disclose any part of your protected health information for treatment, payment, or health care operations. Your request must be made in writing to our Privacy Officer. In your request, you must tell us (1) what information you want restricted; (2) whether you want to restrict our use or disclosure, or both; (3) to whom you want the restriction to apply, for example, disclosures to your spouse; and (4) an expiration date.
If we believe that the restriction is not in the best interest of either party, or that we cannot reasonably accommodate the request, we are not required to agree to your request. If the restriction is mutually agreed upon, we will not use or disclose your protected health information in violation of that restriction, unless it is needed to provide emergency treatment.
You may revoke a previously agreed upon restriction, at any time, in writing.
Right to Request Confidential Communications
You may request that we communicate with you using alternative means or at an alternative location. We will not ask you the reason for your request. We will accommodate reasonable requests, when possible.
Right to Request Amendment
If you believe that the information we have about you is incorrect or incomplete, you may request an amendment to your protected health information as long as we maintain this information. While we will accept requests for amendment, we are not required to agree to the amendment.
Right to an Accounting of Disclosures
You may request that we provide you with an accounting of the disclosures we have made of your protected health information. This right applies to disclosures made for purposes other than treatment, payment, or health care operations as described in this Notice of Privacy Practices. The disclosure must have been made after April 14, 2003, and no more than 6 years form the date of request. This right excludes disclosures made to directly you, to others pursuant to an authorization from you, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to additional exceptions, restrictions, and limitations as described earlier in the Notice.
Right to Obtain a Copy of this Notice
You may obtain a paper copy of this notice from us by requesting one, or printing a copy from our website at www.yourdoctorscare.com.
This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). There are several other privacy laws that also apply to HIV-related information, mental health information, and substance abuse information. These laws have not been superseded and have been taken into consideration in developing our policies and this notice of how we will use and disclose your protected health information.
If you believe these privacy rights have been violated, you may file a written complaint with our Privacy Officer or with the Department of Health and Human Services. No retaliation will occur against you for filing a complaint.
Our Privacy Officer is our business manager and can be contacted at this office or by calling our telephone number. You may contact our Privacy Officer for further information about our complaint process, or for further explanation of this Notice of Privacy Practices. You may also email questions to firstname.lastname@example.org.
Effective June 26, 2012
Section - Certification
|I acknowledge that I have received the Notice of Privacy Form, have read it and have been provided an opportunity to print this document for my records.|
Name of Patient, Parent, Guardian or Personal Representative
Relationship to Patient