NOTICE OF PRIVACY PRACTICES
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.
TREATMENT & HEALTH CARE OPERATIONS
The most common reasons we use your health information are for treatment and health care operations. We routinely use your health information inside our office for the purposes listed below. We will not disclose any of your health information without a signed consent. Examples of how we use information for treatment purposes include: setting up an appointment for you, referring you to another health care provider or getting copies of your health information from another health care provider. “Health care operations” refers to those administrative and managerial functions that we have to do in order to run our office. Examples are: internal quality assurance, business planning and storage of records.
USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written “Authorization to Disclose Medical Information” form. The content of this authorization is determined by federal law. We may initiate the authorization process if we refer you to another health care provider or if we need records from a provider you have seen before (e.g., PAP or lab results, etc…). You may initiate the process if you want us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form from your provider’s office, or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing to our office.
“Authorizations to Disclose Medical Information” forms signed for release of information to non-medical providers, other than the patient, require a health center staff witness to be valid.
APPOINTMENT REMINDERS
We may call, email or write to remind you of scheduled appointments. If you do not want us to call, email or write to you, please send a written request to our office.
USE AND DISCLOSURES FOR OTHER REASONS
In some limited situations, the law allows or requires us to use or disclose your health information without a signed consent form from our office. Not all of these situations will apply to us; most will never come up at our office at all. Such uses or disclosures are:
- When a state or federal law mandates that certain health information be reported for a specific purpose;
- For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
- Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
- Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
- Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
- Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
- Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
- Uses and disclosures to prevent a serious threat to health or safety;
- Uses or disclosure for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
- Disclosures of de-identified information;
- Disclosures relating to worker’s compensation programs;
- Disclosures of a “limited data set” for research, public health, or health care operations
- Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
- Disclosure to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information;
RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
- Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to our office.
- Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to our office.
- Ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to our office.
- Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to our office.
- Get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to our office.
- Get additional paper copies of this Notice of Privacy Practices. If you want additional copies, send a written request to our office.
OUR NOTICE OF PRIVACY PRACTICES
We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change this Notice, we will post the new notice in our office and have copies available in our office.
COMPLAINTS
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to our office. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office at the address or phone number shown at the beginning of this Notice.
Revised 10/2011