Notice of Privacy Practices

Effective Date: September 1, 2013
HIPAA: Health Insurance Portability and Accountability Act

This notice describes how health information about you may be used and disclosed, as well as how you can get access to this information.
Please review it carefully. If you have any questions about this notice, please contact the Office Manager

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination, test results, diagnoses, treatment, a plan for future care or treatment, and billing related information. This notice applies to all of the records of your care generated, whether made by personnel or agents for the clinic.

Our Responsibilities:

We are required by law to maintain the privacy of your health information and provide you with 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 clinical personnel who are involved in taking care of you at the clinic. We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating of once you are discharged.

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 progress 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 it is a covered service under your plan.

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 educational purposes.

Marketing & Any Purposes which Require the Sale of Your Information: The following uses and disclosures of your PHI will be made only with your written authorization: 1) Uses and disclosures of PHI for marketing purposes; and 2) Disclosures that constitute a sale of your PHI. Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose PHI under the authorization. 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 agreed upon services and billing for these services;
• To remind you that you have an appointment for medical care;
• To assess your satisfaction with our services;
• To tell you about possible treatment alternatives;
• To tell you about health-related benefits or services;
• To contact you as part of fundraising efforts; however, you have the right to Opt out;
• For population based activities relating to improving health or reducing healthcare costs; and
• 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. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do, as well as 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. In addition, we may disclose health information about you to an entity assisting in disaster relief effort so that your family can be notified about your condition, status and location.

Research: We may disclose information to researchers when an institutional review board that has reviewed the research proposal and
established protocols to ensure the privacy of your health information has approved their research and granted a waiver of the authorization requirement.

Future Communications: We may communicate to you via email, newsletters, and mailings or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based programs.

Organized Health Care Arrangement: This facility and its medical staff members 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.

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

• Food and Drug Administration
• Public Health of 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
• 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. 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 facility 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. We may deny you the request for an amendment and if this occurs, you will be notified of the reason for the denial.
• Right to Get Notice of a Breach: You have the right to be notified upon a breach of any of your unsecured PHI.
• 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 the 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 the payment for your care, like a family member or friend. For example, you could ask that we do not 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.
• Out-of-Pocket Payments: If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
• 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 facility will grant requests for confidential communications as 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 facility 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 at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
• Right to an Electronic Copy of Electronic Medical Records: If your PHI is maintained in an electronic format you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form.

Changes To This Notice

We reserve the right to change this notice and the revised or changed notice will be elective for information we already have about you as well as any information we receive in the future. The current notice will be posted and include the effective date. In addition, each time you register 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 facility by following the process outlined in the facility’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 records of the care that we provided to you and documented in the office or clinic.