1.
Purpose of this Notice.
We consider any
information that concerns your health, health care or payment for that care to
be confidential and protected information. This Notice describes our privacy
practices, specifically how we use and disclose your medical information and
what rights you have with respect to this information. This information includes
your name, address, and other identifying data, and information on your health
or the health services that have been or may be furnished to you. We require all
of our employees, staff, volunteers and independent contractors to comply with
these privacy practices.
We are required by
federal law to obtain an acknowledgment from you that you received this Notice.
Please sign the attached Acknowledgment Form and return it to any staff member.
Please feel free to
contact our office manager, Mrs. Carol Yaitanes, to discuss, or request any
additional information regarding any of our privacy practice or this Notice.
2.
The Use and Disclosure of Medical Information for Treatment, Payment and Health
Care Operations.
By law we are allowed to
use and disclose your medical information for most purposes related to your
medical treatment (“Treatment”), the payment for your medical treatment
(“Payment”), and our health care operations or the operations of other covered
entities to whom we disclose your medical information (“Operations”).
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Treatment
means the provision,
coordination or management of health care and related services by or involving
one or more health care providers, such as the coordination of consultations and
referrals. For example, we can share most medical information regarding your
health condition with another provider as part of a consultation. We may also
contact you to remind you to make or that you already made an appointment; to
notify you regarding treatment alternatives or other health-related benefits and
services that may be of interest to you, or to raise funds for our own purposes.
Please note that by law,
certain medical information, such as psychotherapy notes, generally may not be
used or shared even when it is related to your treatment, unless we obtain an
Authorization from you to use or release that information.
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Payment
means activities related
to obtaining reimbursement from HMOs, insurers or other payers for services
provided to you. Payment can also cover activities to determine your eligibility
for services with your insurer, coordination of benefits with other insurers,
billing, claims management, collection, medical necessity review activities,
utilization review activities, and disclosure to consumer reporting agencies.
For example, we can disclose to your health plan medical information that is
required by the plan to determine whether the services we have provided to you
are medically necessary. We can also disclose to your health plan a list of the
services that you obtained from us so that we can be paid by the health plan for
providing the services to you.
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Operations
cover a range of
activities that are necessary for the business of health care providers, payors
or clearinghouses (i.e., entities performing certain billing or payment
functions). They may be performed by our employees or, in some cases, by
third-party contractors. These operations include: quality assessment and
improvement activities; peer review; credentialing and licensing; training
programs; legal and financial services; business planning and development;
management activities related to privacy practices; customer services; internal
grievances; creating de-identified information for data aggregation or other
purposes; fundraising; certain marketing activities; and due diligence
activities. For example, we evaluate practitioner performance to ensure that
they meet our quality standards. Engaging counsel to defend us in a legal action
is another activity that is considered health care operations. Another example
involves fundraising activities, in which we, a related foundation or an
independent contractor may contact you in order to raise funds for us.
3.
Authorizations for Other Uses and Disclosures of Your Medical Information.
Unless a use
or disclosure is permitted for treatment, payment or operations purposes under
Section 2 of this Notice, or is permitted or required under Section 4 or 5 of
this Notice, we must obtain a signed Authorization from you to use or disclose
your medical information. We may also require an Authorization when using or
disclosing certain highly protected information, such as substance abuse
information. An Authorization is a written permission that specifically
identifies the information that we will use or disclose, and when and how we
will use or disclose it. You may revoke an Authorization at any time except to
the extent that we have already used or disclosed your information in reliance
on your Authorization.
4.
Use and Disclosure of Medical Information Without Your Consent or Authorization
If You Don’t Object Verbally.
Under certain
circumstances, we may use or disclose your medical information without an
Authorization or other written permission from you if we give you the
opportunity to agree or object verbally. These circumstances are as follows:
a. For our facility
directory. After we have given you the opportunity to refuse, or in an emergency when we
believe that you would want such information to be shared, we can include in our
facility directory your name, location in our facility, general health condition
and religious affiliation. We may also share relevant information in our
directory with clergy or members of the public who inquire about you.
b. To a relative, friend
or individual involved in your care.
We may provide medical
information about you to your relative or friend, or another individual involved
in your care. We will attempt to seek, or, in some circumstances, using our
professional judgment, will infer your permission to make this disclosure. If we
are not able, for instance, because of your condition or because you are not
immediately present, we will use our best judgment to determine whether you
would want this information shared.
c. For disaster relief.
We may use or
disclose your medical information to an entity that assists in disaster relief
efforts.
5. Use and Disclosure of
Medical Information Without Your Consent or Opportunity to Agree or Object
Verbally. In
the following situations, we are permitted under law to use or disclose your
medical information without obtaining your consent or authorization or allowing
you to agree or object.
a. As required by law.
Numerous
state, federal and local laws permit or require certain uses and disclosures of
medical information. However, we may only use or disclose your medical
information to the extent authorized by the law.
b. To business
associates. We may disclose your medical information to our business associates who perform
functions on our behalf if we first receive satisfactory assurance that the
business associate will safeguard your information.
c. For public health
activities. We may be asked or required by law to divulge medical information to a public
health authority under the following circumstances:
i. to report a birth,
death, disease or injury, as required by law;
ii. as part of a public
health investigation;
iii. to report child or
adult abuse or neglect, or domestic violence, as authorized by law;
iv. to report adverse
events (such as product defects), to track products or assist in product recalls
or repairs or replacements, or to conduct post-marketing surveillance, as
required by the Food and Drug Administration;
v. to notify a person
about exposure to a possible communicable disease, as required by law; and
vi. to your employer if,
we are conducting an evaluation relating to the medical surveillance of the
employer’s workplace or to evaluate whether you have a work related injury and
only to the extent that the disclosure concerns such surveillance or injury.
d. For health oversight
activities. Health oversight activities include audits, government investigations,
inspections, disciplinary proceedings, and other administrative and judicial
actions undertaken by the government (or their contractors) by law to oversee
the health care system. We may be asked or required to share medical information
with a health oversight agency for these activities.
e. To report victims of
abuse, neglect or domestic violence.
If we believe that you
are a victim of abuse, neglect or domestic violence, it may report this
information to a
governmental authority, social service or protective services agency if we
believe the disclosure is necessary to prevent serious harm to you or another
individual, if you cannot agree, or if the disclosure is required by law. If we
make such a disclosure, you will be notified promptly unless notification to you
would place you at serious risk of harm or is otherwise not in your best
interest.
f. For judicial and
administrative proceedings. We may disclose medical information as required
by a court or administrative order, or in some instances pursuant to a subpoena,
discovery request or other legal process.
g. To law
enforcement. Police and other law enforcement may seek medical information
from us. We may release this information to law enforcement under limited
circumstances, for example, when the request is accompanied by a warrant,
subpoena, court order, or similar legal process, or when law enforcement needs
specific information to locate a suspect or stop a crime.
h. To coroners,
medical examiners and funeral directors. We may release information
regarding a person who has died as required by law or in order to facilitate
funereal activities.
i. For organ, eye,
and tissue donation. We may provide medical information to organ procurement
organizations and similar entities in order to facilitate organ, eye and tissue
donation and transplantation.
j. For research
purposes. We may be approached by researchers to provide medical information
for research purposes, such as tracking a particular disease. We may provide
medical information to a researcher who has obtained a special waiver that
allows the researcher to collect patients’ medical information without first
obtaining the patients’ permission. These waivers must be obtained from a
committee established under federal law to oversee medical research. The
researcher must demonstrate to the committee that the information is necessary
to the research and poses a minimal risk of an inappropriate use or disclosure.
k. To avert a serious
threat to health and safety. We may use or disclose your medical information
to avert a serious and imminent threat to the health and safety of an individual
or the public.
l. For military and
other specialized government functions.
i. Armed Forces. We may
disclose your medical information if you are a member of the Armed Forces, as
deemed necessary by military command authorities, and if you are foreign
military personnel, to your appropriate authority.
ii. National Security
and Intelligence. We may disclose your medical information to authorized federal
officials for lawful intelligence, counterintelligence, and other national
security activities, and for protective services to the President and other
heads of state or authorized persons.
iii. Correctional
Institutions. If you are an inmate, we may disclose your medical information to
correctional institutions or law enforcement personnel having lawful custody of
you for administration and maintenance of the safety, security and good order of
the correctional institution; of identification necessary to provide health care
to you, or to protect you, other inmates, employees and officers of the
institution, individuals participating in your transportation, or law
enforcement at the institution.
iv. Other Government
Agencies. We may disclose your medical information to other government entities
that administer public benefits to populations similar to the population that we
serve, if necessary to coordinate the functions of the programs.
m. For workers’
compensation.
We may share information
regarding work-related illnesses and injuries in order to comply with workers’
compensation laws.
n. Other permitted
disclosures. We may disclose your medical information as required or permitted by the privacy
regulations promulgated pursuant to the Health Insurance Portability and
Accountability Act, as amended and interpreted from time to time.
a. Restrictions.
You have the right to request in writing to us to restrict how we use and
disclose your medical information. We do not have to agree to the restrictions
that you request. If we do agree to the restrictions that you request, we must
comply with the restrictions, except in emergency circumstances. We also have
the right to ask you to revoke a restriction. Please contact office manager,
Mrs. Carol Yaitanes to request a restriction.
b. Confidential
Communications. You have the right to request in writing that we restrict
the way in which we communicate information regarding your health, health care
services, or payment. For example, you may ask that we communicate with you only
at your home, not at your workplace. We will use reasonable efforts to
accommodate your request. Please contact office manager, Mrs. Carol Yaitanes to
obtain a form to use to make this request.
c. Access. You
have the right to inspect and copy most of your medical information maintained
by us. Normally, we will provide you with access within 30 days of your request.
We may charge a reasonable copying fee. In certain limited instances, we may
deny you access, for example, when the request is for psychotherapy notes. You
have the right to a review of a denial of access to your medical information.
Any request to inspect and copy medical information should be made to office
manager, Mrs. Carol Yaitanes.
d. Amendment. You
have the right to request that we amend your written medical information. For
instance, you can request that we correct an incorrect surgery date in your
records. We will generally amend your information within 60 days of your
request, and will notify you when we have amended your information. We can deny
your request in certain circumstances, such as when we believe that your
information is accurate and complete. You can file a statement of disagreement
to a denial of your request for amendment, to which we may file a rebuttal.
Please direct any request to amend your medical information to office manager,
Mrs. Carol Yaitanes.
e. Accounting.
You have the right to request an accounting from us of certain disclosures
made by us during the 6 years prior to your request, but no earlier than April
14, 2003. We will generally provide you with your accounting within 60 days of
your request. Your request will be filled at no cost to you once every 12
months. For additional accountings, we will notify you in advance of the cost
and give you an opportunity to continue or withdraw your request. These
disclosures do not include those made for purposes of Treatment, Payment or
Operations, those made pursuant to a signed Authorization, or for our facility
directory or other disclosures described in Section 2 of this Notice. Please
forward any accounting request to office manager, Mrs. Carol Yaitanes.
f. Paper Notice.
If you have obtained this Notice electronically, you may obtain a paper copy by
contacting any staff member.
g. Complaints. If
you believe that any of your rights with respect to your medical information
have been violated by us, our employees or agents, you may file a complaint with
us and/or to the Secretary of the U.S. Department of Health and Human Services.
Please contact office manager, Mrs. Carol Yaitanes for a complaint form.
Under no circumstances will we take any retaliation against you for filing a
complaint.
