Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
UNDERSTANDING YOUR HEALTH RECORD/INFORMATION:
Each time you visit a healthcare facility, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care of treatment. This information, often referred to as your health or medical record, serves as a:
- Basis for planning your care and treatment.
- Means of communication among the many health professionals who contribute to your care.
- Legal document describing the care you received.
- Means by which you or a third-party payer can verify that services billed were actually provided.
- A tool in educating health professionals.
- A source of data for medical research.
- A source of information for public health officials who oversee the delivery of health care in the United States.
- A source of data for facility planning and marketing.
- A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
WHO WILL FOLLOW THIS NOTICE:
This notice describes our facility’s practices and that of our staff and physicians
OUR RESPONSIBILITIES REGARDING HEALTH INFORMATION:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive in our office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our office. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
- Maintain the privacy of your health information;
- Give you notice of our legal duties and privacy practices with respect to medical information about you; and
- Follow the terms of the notice that is currently in effect.
- Notify you if we become aware of a breach of your unsecured protected health information.
HOW WE MAY USE AND/OR DISCLOSE YOUR HEALTH INFORMATION:
The following categories describe different ways that we may use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
- For Treatment. We may use health information about you to provide you with medical treatment or services. We may disclose health information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians or other health care providers who will provide services that we do not provide. We may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test. We may also disclose health information to members of your family or others who can help you when you are sick or injured.
- For Payment. We may use health information about you to obtain payment for the services we provide. For example, we give your health insurance company the information it requires so that we may be paid for providing services. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.
- For Health Care Operations. We may use and disclose health information about you for operations necessary for our office to function and make sure our patients receive quality care. For example, our physicians may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide. We may also disclose information to your health insurance company to authorize services or referrals.
- Business Associates. There are some services provided in our organization through contracts with business associates. Examples include our accountants, consultants and attorneys. 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. Our business associates are responsible for safeguarding your information.
- Appointment Reminders. We may contact you to remind you about your appointment(s) for medical care at our facilities.
- Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you
- Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
- Fundraising Activities. We may use medical information about you to contact you as part of a fund-raising effort. If you do not wish to be contacted regarding our fundraising efforts please notify our office and we will honor your wishes.
- Notification. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition. If we are unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided us, e.g., on an answering machine.
- Communication with Family. We may release medical information about you to a family member, other relative, friend or any other person you identify who is involved in your medical care. We may also give information to someone who helps pay for your care.
- Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. However, all research projects are subject to a special approval process and protocols to ensure the privacy of your health information.
- As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law.
- To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
- Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
- Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
- Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
- Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
- To prevent or control disease, injury or disability.
- To report births and deaths.
- To report child abuse or neglect.
- To report reactions to medications or problems with products.
- To notify people of recalls of products they may be using.
- To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
- To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
- To report immunization status to a school for enrollment purposes if the patient or their personal representative consents to the disclosure. The consent may be verbal.
- Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
- Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
- Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the facility; and
- In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
- Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner, medical examiner and funeral directors as necessary to carry out their duties consistent with applicable law.
- Correctional Institution. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the institution or official as necessary for your health and safety and for the health and safety of others.
- National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
- Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
YOUR HEALTH INFORMATION RIGHTS:
Although your health record is the physical property of the facility, you have the following rights regarding the information we maintain about you:
- Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy this medical information, you must submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. If you request a copy in an electronic format we may charge you for our labor costs.
- Right to Amend. If you feel that medical 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 for or by our office. To request an amendment, your request must be made in writing and submitted to our office. In addition, you must provide a reason that supports your request. We ask that you use the form provided by our facility to make such requests. For a request form please contact our office. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the medical information kept by or for the facility;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
- Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. Please note that an accounting will not apply to any of the following types of disclosures:
- Disclosures made for reasons of treatment, payment or health care operations;
- Disclosures made as a result of a signed authorization;
- Disclosures made for directory or other notification purposes;
- Disclosures made to you or your legal representative or any other individual involved with your care;
- Disclosures to correctional institutions and other law enforcement custodial situations;
- Disclosures made for national security purposes.
To request this list or accounting, you must submit your request in writing to our office. We ask that such requests be made on a form provided by our facility. For a request form please contact our office. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. In addition, you have the right to request that we restrict disclosure of your medical information if the disclosure is to a health plan for the purpose of carrying out payment or health care operations and the medical information pertains solely to a health care item or service for which you have paid out of pocket in full. 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. We ask that you use the form provided by our office. In your request you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
- Right to 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 only contact you at work or by mail. We ask that you use the form provided by our office and your request must be in writing. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- Right to 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.
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. The following is a description of some situations where our use and disclosure of your medical information will require your written permission:
- Psychotherapy Notes – Most uses and disclosures of these notes will require your written permission. Psychotherapy notes are made by a mental health professional documenting or analyzing the contents of his/her conversations with you during a counseling session and that are kept separate from the rest of your medical record.
- Marketing Purposes – Subject to limited exceptions, uses and disclosures of your medical information for marketing purposes will require your written permission.
- Sale of Medical Information – Disclosures that would constitute the sale of your medical information will require 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 records of the care that we provided to you.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the facility. The notice will contain on the last page, at the bottom left-hand corner, the effective date. In addition, each time you register at or are admitted to the facility for treatment or health care services as an inpatient, outpatient or resident, we will offer you a copy of the current notice in effect.
FOR MORE INFORMATION OR TO REPORT A PROBLEM:
If you have questions and would like additional information, you may contact our office at 970-858-2122. If you believe your privacy rights have been violated, you may file a complaint with our office. A complaint must be made in writing on a form provided by our office, and when completed, should be returned to the same. You may also file a complaint with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.
Effective Date: April 20, 2017