NOTICE OF THE USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

 

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.

 

I am required by federal law to maintain the privacy of your Protected Health Information, and to provide you with notice of my legal duties and privacy practices regarding Protected Health Information. “Protected Health Information” is information that I keep in electronic, paper or other form, including demographic information collected from you and is created or received by me and relates to your past, present, or future physical or mental health or condition, the provision of health care services to you, or the past, present, or future payment for the health care services I deliver to you, and that identifies you or which I reasonably believe can be used to identify you.

 

I am required by federal law to comply with the terms of this Notice. I reserve the right to make changes in my privacy practices regarding your Protected Health Information. If I change my privacy practices, that change will apply to all Protected Health Information that I maintain about you. However, if I change our privacy practices, I will provide you with written notice of any changes at the time of your next visit following such changes.

 

I may use and disclose your Protected Health Information for a variety of purposes. For example:

 

1. : I may disclose your Protected Health Information to another physician, such as a specialist or primary care physician, to whom I refer you for medical treatment or to a physician who has referred you to me.

2. : I may disclose your Protected Health Information to a health plan, managed care plan, individual practice association or to a management services organization that analyzes my delivery of medical services to evaluate my health care quality management, case management or professional competence. I may also provide your Protected Health Information to other health care providers, such as laboratories or ambulance companies, for purposes of their health care operations.

3. : I may disclose your Protected Health Information to obtain payments. Disclosures for “payment” include: (a) disclosure to a health plan to determine your eligibility or coverage under the plan; (b) disclosures to a health plan to obtain reimbursement for delivering medical services to you; (c) disclosures to billing services or collection agencies; (d) disclosures for utilization management and determinations of whether the medical services I deliver to you are necessary or appropriate; or (e) disclosures to determine whether the amount I charge you for medical services is justifiable.

4. : I may contact you to provide you with appointment reminders or information about medical treatment alternatives or other health-related benefits and services that may be of interest to you.

 

I may use or disclose your Protected Health Information in connection with treatment, payment or health care operations if I deliver health care products or services to you based on the orders of another health care provider, and I report the diagnosis or results associated with the health care services directly to another health care provider, who provides the products or reports to you. I may use or disclose your Protected Health Information that was created or received in emergency treatment situations, to carry out treatment, payment, or health care operations if I attempt to obtain your consent as soon as reasonably practicable after the delivery of such treatment.

 

I may disclose your Protected Health Information without your authorization in the following circumstances: (a) for public health activities, such as controlling communicable diseases, reporting child abuse or neglect, to monitor or evaluate the quality, safety or effectiveness of FDA-related products or services; (b) for reporting victims of abuse, neglect or domestic violence; (c) for health oversight activities, such as overseeing government benefit programs; (d) in response to judicial or administrative orders, such as subpoenas; (e) for law enforcement purposes, such as mandatory reporting of certain types of wounds, or identifying or locating individuals; (f) for certain research purposes; (g) to avert a serious threat to the health or safety of an individual or the general public; and (h) for selected governmental functions, such as national security. In each of these situations I will keep records that explain my attempt to obtain your consent and the reason why consent was not obtained.

 

I am required to disclose your Protected Health Information: (a) to you upon your request and upon payment by you of reasonable fee for supervision of your review or copying; and (b) to the U.S. Department of Health and Human Services (“DHHS”) when DHHS investigates to determine whether I am complying with federal law.

 

In all other circumstances I must obtain your authorization to use or disclose your Protected Health Information. You will be required to sign an authorization form which permits me to use and disclose your Protected Health Information for certain purposes, and I may not condition the delivery of medical treatment to you on your providing the requested written authorization. You have the right to revoke your authorization in writing as long as I have not acted in reliance on the authorization.

 

You have the following rights with respect to your Protected Health Information:

 

1. The right to request restrictions on my use and disclosure of your Protected Health Information for treatment, payment or health care operations. If I agree to any restriction, then I cannot violate that restriction except in the case of emergency treatment. However, I am not required to agree to any restrictions.

2. The right to request in writing and to receive confidential communications of your Protected Health Information by alternative means (such as by mail or facsimile) or at alternative locations (such as your office or business workplace).

3. The right to request in writing access to my office to inspect and copy your Protected Health Information. Except in cases where the Protected Health Information is not maintained or accessible on-site, I will act on a request for access no later than thirty (30) days after I receive your request.

4. The right to request in writing that I amend your Protected Health Information. Your request must contain the reasons to support the requested amendment. I will act upon your request within sixty (60) days after I receive your request.

5. The right to receive an accounting of all my disclosures of your Protected Health Information in the six years prior to the date of your request, except for disclosures: (a) to carry out any treatment, payment and health care operations; (b) to you; (c) to persons involved in your care; (d) for national security or intelligence purposes; (e) to correctional institutions or law enforcement officials; (f) pursuant to any written authorization that you give to me; or (g) that occurred prior to April 14, 2003.

6. The right to request and obtain from me a paper copy of this Notice at a reasonable cost to you.

 

If you believe that I have violated your privacy rights, then you may file a written complaint to Michelleen Perreira, who is my privacy officer. You may also file a complaint with the Office for Civil Rights of the DHHS. Your complaint must: (a) be in writing, either on paper or electronically; (b) name the Company and describe the acts or omissions you believe to be in violation of the Privacy Rules; (c) be filed within 180 days of when you knew or should have known that the act or omission complained of occurred, unless the time limit is waived by the DHHS for good cause shown. The complaint may be sent to: Office of Civil Rights, U.S. Department of Health and Human Services, Region IX, 50 United Nations Plaza, Room 322, San Francisco, CA 94102. I will not retaliate against you for filing a complaint. If you wish to obtain additional information about any of the matters discussed in this notice you may contact my privacy officer Michelleen Perreira at (808) 622-2626.