We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to keep your health information private, give you this notice of our legal duties and privacy practices and follow the terms of this notice.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose health information. For each category of disclosures, we will explain what we mean and try to give some examples. Not every disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices, at the hospital if you are hospitalized under our supervision or at another doctor’s office, lab, pharmacy, or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. 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 tell the dietitian at the hospital if you have diabetes so that we can arrange appropriate meals. We may also disclose health 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.
We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
PUBLIC HEALTH RISKS:
We may disclose health information about you for public health activities. These activities generally include the following:
• Prevent or control disease, injury or disability
• Report births or deaths
• Report child abuse or neglect to the proper authorities
• Report reactions to medications or problems with products
• Notify people of recalls of products they may be using
• Notify a person who may have been exposed to a disease or at risk for contracting or spreading a disease or condition
• Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES:
We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
You have the following rights regarding health information we maintain about you: Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billing records. This does not include psychotherapy notes. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our 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.
RIGHT TO AMEND:
If you feel that the health information, we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing, submitted to our Office Manager, and must be contained on one page of paper legibly handwritten or typed in at least 10-point font size. In addition, you must provide a reason that supports your request for amendment. 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
• is not part of the health information kept by or for our practice;
• is not part of the information which you would be permitted to inspect and copy; or
• is judged to be accurate and complete any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.
RIGHT TO AN ACCOUNTING OF DISCLOSURES:
You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described. To request this list of disclosures, you must submit your request in writing to our Office Manager. Your request must state a time period which may not be longer than six years, and may not include dates, before January 1, 2022. The first list you request within a 12- month period will be free. 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. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.
RIGHT TO REQUEST RESTRICTIONS:
You have the right to request a restriction or limitation on the health 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 health information we disclose about you to someone who is involved in your care of the payment for your care, such as a family member or friend. For example, you could ask that we restrict a specified nurse from use of your information, or that we not disclose information to your spouse about a surgery you had. We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request a restriction, you must make your request in writing to our Office Manager. In your request, you must tell us what information you want to limit and to whom you want the limits to apply; for example, use of any information by a specified nurse, or disclosure of specified surgery to your spouse. Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box. To request confidential communications, you must make your request in writing to our Office Manager. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
RIGHT TO A PAPER COPY OF THIS NOTICE:
You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from our Office Manager.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. In addition, each time you register for treatment or health care services, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Office Manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Our notice of Privacy Practice provides information about how we may use and disclose protected health information (PHI) about you. As stated in our notice, the terms of the notice may change. If we change our notice, you may obtain a revised copy by contacting the Privacy Office(r) at IVUSE, LLC. By signing this form, you acknowledge that you have a copy of our Notice of Privacy Practices.