NOTICE of PRIVACY PRACTICES for
PROTECTED HEALTH INFORMATION
As required by the Privacy Regulations created as a result of the Health Insurance Portability & Accountability Act of 1996 (HIPAA)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION
ABOUT YOU (AS A PATIENT OF THIS PRACTICE)
MAY BE USED & DISCLOSED, AND HOW YOU CAN GET
ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
PLEASE REVIEW THIS NOTICE CAREFULLY
The HIPAA Privacy Rule gives individuals a fundamental right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information. Health plans and covered health care providers are required to develop and distribute a notice that provides a clear explanation of these rights and practices. This notice is intended to inform you on privacy issues and concerns, and to prompt you to have discussions with your health plans and health care providers and exercise your rights.
The Privacy Rule also provides that an individual has a right to adequate notice of how a covered entity may use and disclose protected health information about the individual, as well as his or her rights and the covered entity’s obligations with respect to that information. Most covered entities must develop and provide individuals this notice of their privacy practices.
The following 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.
- OUR COMMITMENT TO YOUR INFORMATION PRIVACY
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding to you and your treatment, as well as the services we provide to you. We are required by the law to maintain the confidentiality of health information that identifies you. We are also required by the law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. According to Federal and State Law, we must follow the terms of the notice of privacy practices that we have in effect at the time. Also, you can ask to see or get an electronic or paper copy of your medical record and other health information we have about you (ask us how to do this).
We realize that the abovementioned Law and related Regulations are verbose and complicated. Hence, below we provide you concise information on the following important issues:
- How we may use or disclose your IIHI
- Your privacy rights concerning your IIHI
- Our obligations concerning the use and disclosure of your IIHI
The terms of the present Notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this Notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our currently active Notice in our offices at a visible location at all times, and you may request its copy at any time.
Effective Date of this Notice:____________________
- IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT
- WE MAY USE & DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS
The categories below describe the different ways in which we may use and disclose your IIHI.
1. Treatment. Our practice may use your IIHI for your treatment. For example, we may ask you to have laboratory tests (e.g., blood or urine tests), and we may use the results to help us reach the correct diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy while ordering a prescription for you. Many people who work for our practice, including – but not limited to – our doctors and nurses, may use or disclosure your IIHI in order to treat you or to assist others in your treatment. In addition, we may disclose your IIHI to other persons who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your IIHI to other health care providers for purposes related to your treatment.
2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment, to determine if your insurer will cover, or pay for, your treatment. We may also use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. In addition, we may use you’re your IIHI to bill you directly for provided services and items. We may disclose your IIHI to other health care providers and entities to assist in their billing and payment collection efforts.
3. Health Care Operations. Our practice may use and disclose your IIHI to operate our business. As examples of the ways we may use and disclose your personal information for our operations, our practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our general practice. We may disclose your IIHI to other health care providers and entities to assist in their health care operations.
4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind you of an appointment.
5. Release of Information to Family/Friends. Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this case, the babysitter may have access to this child’s medical information.
6. Disclodure Required by Law. Our practice will use and disclose your IIHI when we are required to do so by Federal, State or Local Law.
Effective Date of this Notice:________________
- USE & DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique (special) scenarios when we may use or disclose you identifiable health information.
1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by Law to collect information for the purpose of:
- Maintaining vital records, such as birth and death (e.g., coroner, medical examiner)
- Reporting child abuse or neglect
- Preventing or controlling disease, injury or disability
- Notifying a person with regard to a potential exposure to a communicable disease
- Notifying a person with regard to a potential risk of spreading or contracting a disease or condition
- Reporting reactions to drugs or problems with certain products or devices
- Notifying individuals if a product or device they may be using has been recalled
- Notifying relevant Government Agency(ies) and authority(ies) with regard to potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by Law to disclose this information
- Notifying your employer (under limited circumstances) primarily on workplace injury or illness or medical surveillance
- Sharing information with the Department of Health and Human Services if it wants to see that we’re complying with Federal Privacy Law
- Sharing information for special Government functions such as military, national security, and Presidential protective services
- Respond to lawsuits and legal actions
- For law enforcement purposes or with a law enforcement official.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for activities authorized by Law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; other activities necessary for the Government to monitor Government programs, compliance with civil rights’ laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We may also disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you about the request or to obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release your IIHI if asked to do so by a law enforcement official:
- Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
- Effective Date of this Notice:____________________
- Concerning a death we believe has resulted from criminal conduct
- Regarding criminal conduct at our offices
- In response to a warrant, summons, court order, subpoena or similar legal process
- To identify/locate a suspect, material witness, fugitive or missing person
- In an emergency case, to respond a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).
5. Deceased Patients. Our practice may release your IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information to funeral directors to perform their jobs in due form.
6. Research. Our practice may use and disclose your IIHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your IIHI for research purposes except when an Institutional Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers, or such retention is otherwise required by Law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entitu (except as required by Law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.
7. Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety, or the health and safety of another individual(s) or the public. Under these circumstances, we will only make disclosures to a person or organization in charge of (able) to help prevent the threat.
8. Military. Our practice May disclose your IIHI if you are a member of US or foreign military forces (including veterans), and if required by the appropriate authorities.
9. National Security. Our practice may disclose your IIHI to Federal officials for intelligence and national security activities authorized by the Law. We may also disclose your IIHI to Federal officials in order to protect the President, other officials or foreign Heads of State, or to conduct an investigation.
Effective Date of this Notice:____________________
10. Inmates. Our practice may disclose your IIHI to correctional institutions or Law enforcement officials if you are an inmate or under the custody of a Law enforcement official. A disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you; (b) for the safety and security of the institution; and/or (c) to protect your health and safety or the health and safety of other individuals.
11. Workers’ Compensation. Our practice may release your IIHI for workers’ compensation and similar programs.
Effective Date of this Notice:____________________
- YOUR RIGHTS REGARDING YOUR IIHI
You have the following rights regarding the IIHI that we maintain about you.
1. Confidential Communication. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. In order to request a type of confidential communication, you must make a written request to [insert name, or title, and telephone number of a person or office to contact for further information] specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment of your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by Law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your IIHI, you must make your request in writing to [insert name, or title, and telephone number of a person or office to contact for further information]. Your request must describe the following in a clear and concise way:
(a) The information you wish to be restricted
(b) Whether you are requesting to limit our practice’s use, or disclosure, or both; and
(c) To whom you want the limits to be applied.
3. Inspection & Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to [insert name, or title, and telephone number of a person or office to contact for further information] in order to inspect and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by for our practice. To request an amendment, your request must be made in writing and submitted to [insert name, or title, and telephone number of a person or office to contact for further information]. You must provide us with a reason that supports your request for amendment . Our practice will deny your request if you fail to submit your request (and the reason supporting it) in writing. Also, we may deny your request if you ask us to amend information that is, in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI wich you would be permitted to inspect or copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures”. An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your IIHI for
Effective Date of this Notice:____________________
Non-treatment, non-payment or non-operation purposes. Use of you IIHI as part of the routine patient care in our practice is not required to be documented. For example: the doctor, sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to [insert name, or title, and telephone number of a person or office to contact for further information]. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure, and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge; but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with the additional requests, and you may withdraw your request before you incur any costs.
6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our Notice of Privacy practices. You may ask to give you a copy of this Notice at any time. To obtain a paper copy of this Notice, contact [insert name, or title, and telephone number of a person or office to contact for further information].
7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact [insert name, or title, and telephone number of a person or office responsible for complaints]. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses & Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this Notice or permitted by applicable Law. Any authorization you provide to us regarding the use and disclosure of your IIHI, may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note: we are required to retain records of your care.
Once more: If you have any questions regarding this Notice or our health information privacy, please contact:
Our clinic at: