THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUTYOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.
If you have any questions about this notice, please contact:
This notice was published and becomes effective on April 14, 2003
Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal
and we are committed to maintaining the confidentiality of your medical
information. We create and maintain a record of the care and services
that you receive at our practice. We need this record to treat you and
to comply with certain legal requirements. This notice applies to all
of the records of your care generated by our practice, whether made by
your personal doctor or by other personnel within our practice.
This notice advises you about the ways in which we may use and disclose
medical information about you. It also describes your rights to access
and control your medical information. 'Medical information' is information
about you, including demographic information, that may identify you and
that relates to your past, present or future physical or mental health
or condition and related health care services. This notice also describes
your rights and explains certain obligations we have regarding the use
and disclosure of medical information.
We are required by law to:
Make sure that medical information that identifies you is kept private.
Provide you with this notice of our legal duties and privacy practices
with respect to medical information about you.
Follow the terms described in this notice.
We may change the terms of this notice at any time. The new notice will
be effective for all protected health information that we maintain at
that time. Upon your request, we will provide you with any revised NOTICE
OF PRIVACY PRACTICES by calling our office and requesting that a revised
copy be sent to you in the mail, by asking for one at the time of your
next office visit, or by accessing our website at:
How We May Use and Disclose Medical Information About You
The following categories describe different ways that we may use and
disclose medical information. For each category of uses or disclosures,
we will explain what we mean and provide examples. Not every use or disclosure
in a category will necessarily be listed below. However, all of the ways
which we are permitted to use and disclose information will fall within
one of the categories.
Treatment - We may use medical information about you to provide
you with medical treatment or services. We may disclose medical information
about you to doctors, nurses, technicians, medical students, or other
practice personnel who are involved in your medical care and treatment.
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. In addition,
the doctor may need to inform the dietitian if you have diabetes so that
we can arrange for you to receive information regarding appropriate meals.
Different areas of the practice also may share medical information about
you in order to coordinate the different things you need, such as prescriptions,
lab work and x-rays. We also may disclose medical information about you
to people outside the practice who may be involved in your medical care
after you leave our office, such a family members, clergy or others we
may rely upon or ask to assist us in caring for you.
Payment - We may use and disclose medical information about you
so that the treatment and services which we provide to you at our practice,
or at a hospital, ambulatory surgery center, nursing home or other site
may be billed to and payment may be collected from you and/or your insurance
company or other responsible third party. For example, we may need to
provide to your health insurance plan information about the services which
we provided to you at our practice, hospital or ambulatory surgery center,
so that your health plan will pay us or reimburse you for the services.
We may also advise your health insurance plan about a treatment you are
going to receive in order to obtain prior approval or to determine whether
your plan will cover the treatment.
Health Care Operations - We may use and disclose medical information
about you for our practice operations. These uses and disclosures are
necessary to operate our practice and make sure that all of our patients
receive quality core. For example, we may use medical information to review
our treatment and services and to evaluate the performance of our staff
in caring for you. We may also combine medical information about many
practice patients to decide what additional services the practice should
offer, what services are not needed, and whether certain new treatments
are effective. We may also disclose information to doctors, nurses, technicians,
medical students, and other practice personnel for review and learning
purposes. We may also combine the medical information we have with medical
information from other practices to compare how we are doing and see where
we can make improvements in the care and services that we offer. We may
remove information that identifies you from this set of medical information
so others may use it to study health care and health care delivery without
learning who the specific patients are.
Appointment Reminders - We may use and disclose medical information
in connection with our efforts to remind you that you have on appointment.
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. For example, we may use your information
to determine whether you qualify for a nutritional counseling program.
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 or disclose your demographic
information and the dates that you received treatment from your doctor,
as necessary, in order to contact you for fund raising activities supported
by our practice. If you do not want to receive these materials, please
contact our Privacy Contact and request that these fundraising materials
not be sent to you.
Ambulatory Surgery Center Registry -If your care or services
are performed at an ambulatory surgery center that is part of our practice,
we may include certain limited information about you in the ambulatory
surgery registry while you are a patient at the ambulatory surgery center.
This information may include your name, location within the ambulatory
surgery center, the facility directory, your general condition (e.g.,
fair, stable, etc.) and your religious affiliation. The registry information,
except for your religious affiliation, may also be released to people
who ask for you by name. Your religious affiliation may be given to a
member of the clergy, even if they don't ask for you by name. This is
so your family, friends and clergy can visit you in the ambulatory surgery
center and generally be advised of how you are doing.
Individuals Involved in Your Care or Payment for Your Care -
We may release medical information about you to a friend or family member
who is involved in your medical care. We may also give information to
someone who helps pay for your care. For example, a babysitter responsible
for the care of a child may be provided with certain information about
the treatment which we provided to the child. We may also advise your
family or friends about your condition and that you are in a hospital,
ambulatory surgery center or at our office. In addition, we may disclose
medical information about you to an entity assisting in a disaster relief
effort so that your family can be notified about your condition, status
and location.
Research - Under certain circumstances, we may use and disclose
medical information about you for research purposes. For example, a research
project may involve comparing the health and recovery of all patients
who received one medication to those who received another, for the same
condition. All research projects, however, are subject to a special approval
process. This process evaluates a proposed research project and its use
of medical information, trying to balance the research needs with patients'
need for privacy of their medical information. Before we use or disclose
medical information for research, the project will have been approved
through this research approval process. We may, however, disclose medical
information about you to people preparing to conduct a research project,
for example, to help them look for patients with specific medical needs,
so long as the medical information they review does not leave the practice.
We will almost always ask for your specific permission if the researcher
will have access to your name, address or other information that reveals
who you are, or will be involved in your care at the practice.
SPECIAL SITUATIONS - Other Permitted and Required Uses and Disclosures
That May Be Made Without Your Consent, Authorization or Opportunity to
Object:
Emergencies - We may use or disclose your medical information
in an emergency treatment situation. If this happens, your doctor shall
try to obtain your consent as soon as reasonably practicable after the
delivery of treatment. If your doctor or another doctor in the practice
is required by law to treat you and the doctor has attempted to obtain
your consent but is unable to obtain your consent, he or she may still
use or disclose your medical information in order to treat you.
Communication Barriers - We may use and disclose your medical
information if your doctor or another doctor in the practice attempts
to obtain consent from you but is unable to do so due to substantial communication
barriers and the doctor determines, using professional judgment, that
you intend to consent to use or disclosure under the circumstances.
Coroners. Medical Examiners and Funeral Directors - We may release
medical information to a coroner or to a medical examiner. This may be
necessary, for example, to identify a deceased person or to determine
the cause of death. We may also release medical information about patients
to funeral directors as necessary to carry out their duties.
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.
As Required By Law - We will disclose your medical information
when required to do so by federal, state or local law. The use or disclosure
will be made in compliance with the law and will be limited to the relevant
requirements of the law.
Legal Proceedings -If you are involved in a lawsuit or a dispute,
we may disclose medial! 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 required by law or
if efforts have been made to tell you about the request or to obtain an
order protecting the information requested.
Public Health - 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 hove 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. In this
case, the disclosure will be made consistent with the requirements of
applicable federal and state laws.
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.
Law Enforcement - We will disclose medical information when required
to do so for law enforcement purposes. These law enforcement purposes
include: (1) legal processes and otherwise required by law, (2) limited
information requests for identification and location purposes, (3) pertaining
to victims of a crime, (4) suspicion that death has occurred as a result
of criminal conduct, (5) in the event that a crime occurs on the premises
of the practice, and (6) medical emergency (not on the practice's premises)
and it is likely that a crime has occurred.
Criminal Activity - Consistent with applicable federal and state
lows, we may disclose your medical information, if we believe that the
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 medical information if it is necessary for law enforcement authorities
to identify or apprehend an individual.
Inmates -If you are an inmate of a correctional facility or under
the custody of a law enforcement official, we may release medical information
about you to the correctional facility or law enforcement official. This
release would be necessary (1) for the institution to provide you with
health care; (2) to protect your health and safety or the health and safety
of others; or (3) for the safety and security of the correctional institution.
National Security and Intelligence Activities - We may release
medical information about you to authorized federal officials for intelligence,
counterintelligence, protection of the President, other authorized persons
or foreign heads of state, for purpose of determining your own security
clearance and other national security activities authorized by law.
Military and Veterans -If you are a member of the armed forces,
we may release medical information about you us required by military command
authorities. We may also release medical information about foreign military
personnel to the appropriate foreign military authority. If you are a
member of the Armed Forces, we may disclose medical information about
you to the Deportment of Veterans Affairs upon your separation or discharge
from military services. This disclosure is necessary for the Deportment
of Veterans Affairs to determine whether you are eligible for certain
benefits.
Workers' Compensation - We may release medical information about
you to comply with worker's compensation laws or similar programs. These
programs provide benefits for work-related injuries or illness.
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. Under the law, we must make disclosures to you and when required
by the Secretary of the Department of Health and Human Services to investigate
or determine our compliance with the requirements of Section 164500 et.
seq.
Your Rights Regarding Medical Information About You
You have the following rights regarding medical 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 and any other
records that your doctor and the practice use for making decisions about
you. We may deny your request to inspect and copy in certain limited circumstances.
Under federal law, you may not inspect or copy (1) psychotherapy notes;
(2) information compiled in reasonable anticipation of, or use in, a civil,
criminal, or administrative action or proceeding; (3) medical information
that is subject to law that prohibits access to medical information. If
you are denied access to medical information, you may request that the
denial be reviewed. Another licensed health care professional chosen by
the practice 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.
To inspect and copy medical information that may be used to make decisions
about you, you must submit your request in writing to our office Privacy
Contact. If you request a copy of the information, we may charge a fee
as permitted by state law for the costs of copying, mailing or other supplies
associated with your request.
Right to Amend -If you feel that medical information we have about you
is incorrect or incomplete you have the right to request on amendment
for as long as the information is maintained by the practice. Your request
must be made in writing to our Privacy Contact and you must provide a
reason that supports your request. 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 maintained by the practice.
Is not part of the information which you would be permitted to inspect
and copy.
Is accurate and complete.
Right to Request Confidential Communications - You have the right
to request that we communicate with you about medical matters in an alternative
way or at an alternative location. For example, you can ask that we only
contact you at work or by mail. We will accommodate reasonable requests
and we will not request an explanation for your request. Please make this
request in writing to our practice Privacy Contact.
Right to Request Restrictions - You hove 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. For example, you could ask that we not
use or disclose information about a surgery that you had. Your request
must be made in writing to our office Privacey Contact and you must tell
us (1) what information you want to limit; (2) whether you wont to limit
our use, disclosure or both; and (3) to whom you want the limits to apply,
for example, disclosures to your spouse.
The practice is not required to agree to your request. If your doctor
believes it is in your best interest to permit the use and disclosure
of your medical information, then your medical information will not be
restricted. If we do agree, we will comply with your request unless the
information is needed to provide you with emergency treatment. With this
in mind, please discuss any restriction you wish to request with your
doctor.
Right to an Accounting of Disclosures - You hove the right to
request an "accounting of disclosures: This is a list of the disclosures
we made of medical information about you. This right applies to disclosures
other than purposes of treatment, payment or health care operations as
described in this Notice of Privacy Practices. It excludes disclosures
we may have made to you, for a facility directory, to family members or
friends involved in your care, or for notification purposes. Your request
must be made in writing to our office Privacy Contact and must indicate
a time-period that may not be longer than six years and may not include
dates prior to 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 provided at no cost to you.
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 a Paper Copy of This Notice - You hove the right to a
paper copy of this notice, even if you have agreed to receive this notice
electronically. You may ask us to provide you with a ropy of this notice
at any time.
Complaints
If you believe your privacy rights have been violated, you may file a
complaint with the practice or with the Secretary of the Department of
Health and Human Services. All complaints must be made in writing.
You wiII not be penalized for filing a complaint.
To file a complaint with the practice, contact our office Privacy Contact
listed on page 1 of this notice.
Other Uses of Medical Information
Other uses and disclosures of medical 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 medical 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 medical
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.
Patient Instructions
Please complete by signing and dating the Patient's Acknowledgement section
below. Detach this page at the perforation and retain the original NOTICE
OF PRIVACY PRACTICES for your records.
RETURN ONLY THIS PAGE TO OUR OFFICE
Patient's Acknowledgement
I hereby acknowledge that I have been provided with the practice's NOTICE
OF PRIVACY PRACTICES and that I have read and fully understand the notice.
I have been provided the opportunity to ask questions about the notice
and my questions have been answered to my satisfaction.
