As required by privacy regulations created as a result of the Health Insurance Portability/Accountability Act of 1996, THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU MAY ACCESS THIS INFORMATION. PLEASE READ CAREFULLY. Within this document the patient is referred to as “you”. If you are a parent or legal guardian of the patient, reading this notice will inform you of the clinic’s policies regarding your child’s medical information and how it will be handled.
Commitment to Privacy:
This clinic is committed to maintaining the privacy of your protected health information (PHI). We are required by law to maintain the confidentiality of your health information. We also are required by law to provide you with this notice of our legal cuties and privacy practices that we maintain in this clinic concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect.
We recognize that these laws are complicated, but we must provide you with the following important information:
• How we may use and disclose your PHI.
• Your privacy rights regarding your PHI.
• Our obligations concerning the use and disclosure regarding your PHI.
We May Use and Disclose Your Protected Health Information (PHI) in the Following Ways:
1. Treatment – This clinic may use your PHI for treatment purposes. We may disclose your PHI to other health care providers for purposes related to your treatment. This may include, but is not limited to, your doctor, other providers, caseworkers, and school related personnel.
2. Payment – This clinic may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs.
3. Health Care Operations – This clinic may use and disclose your PHI to operate our business. An example of this is, using your PHI to evaluate the quality of care you receive from us.
4. Appointment – This clinic may use and disclose your PHI to contact you and remind you of an appointment. An example of this is, leaving a message on your answering machine.
5. Release of Information to Family/Friends – This clinic may release your PHI to a friend or family member that is involved in your care. For example, if a friend, babysitter, grandparent, or other family member brings you or your child to the clinic for care, they will receive medical information about you or that child.
6. Disclosures Required by Law – This clinic will use and disclose your PHI when we are required to do so by federal, state, and/or local law.
Uses and Disclosure of your PHI in Certain Special Circumstances:
1. Public Health Risks – This clinic may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of reporting child abuse or neglect, maintaining vital records, preventing or controlling disease, injury or disability, notifying a person regarding a potential risk for spreading or contracting a disease or condition, reporting problems with products or devices, notifying individuals that a product or device they may be using has been recalled, or notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
2. Health Oversight Activities – This clinic may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities may include investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or 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 – This clinic may use and disclose your PHI in response to a court order, if you are involved in a lawsuit or similar proceedings.
4. Law Enforcement – This clinic may release PHI if asked to do so by a law enforcement official regarding a crime victim. If we are unable to obtain the person’s agreement, concerning what we believe has resulted from criminal conduct, regarding criminal conduct at our offices, in response to a warrant, summons, court order, or similar legal process, to identify/locate a suspect, material witness, fugitive or missing person, or in an emergency, to report a crime.
5. Serious Threats to Health and Safety – This clinic may use and disclose your PHI when necessary to reduce or prevent a serious threat to you or your child’s health and safety or the health and safety of another individual.
6. Military – This clinic may disclose your PHI if you are a member of US or foreign military forces and if required by the appropriate authorities.
7. National Security – This clinic may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
8. Inmates – This clinic may disclose your PHI to correctional institutions or law enforcement officials if you or your child is an inmate or under the custody of law enforcement officials. Disclosure for these purposes would be necessary for the institution to provide health care service to you or your child, for the safety and security of the institution and to protect your health and safety or the health and safety of other individuals.
9. Worker’s Compensation – This clinic may release your PHI for workers’ compensation and similar programs.
Your Rights Regarding Your PHI:
You have the following rights regarding the PHI that we maintain about you or your child. Request involving your rights must be submitted in writing.
1. Confidential Communications – You have the right to request that our clinic communicate with you about health related issues in a particular manner, or at a certain location. The request must specify the method of contract, or the location where you wish to be contracted. We 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 PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment of your care. 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. Your request must describe in a clear and concise fashion the information you wish restricted, whether you are requesting to limit our clinic’s use, disclosure or both, and to whom you want the limits to apply.
3. Inspection and Copies – You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you or your child, including patient medical records, and billing records. This clinic may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial.
4. Amendment – You may ask us to amend your health information if you believe it is incorrect or incomplete. You may request an amendment for as long as the information is kept by or for this clinic. You must provide us with a reason that supports your request for the amendment. Also, we may deny your request if you ask us to amend information that is in our opinion accurate and complete, not part of the PHI, not created by our clinic, or the individual/entity that created the information is not available to amend the information.
5. Accounting of Disclosure – All of our patients have the right to request on “accounting of disclosures” which is a list of certain non-routine disclosures our clinic has made of your PHI for non-treatment, non-payment, or non-operations purposes. Use of your PHI as part of the routine patient care in our clinic is not required to be documented. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six years from the date of disclosure and may not include dates before April 15, 2003.
6. Right to a Paper Copy of this Notice – You are entitled to receive a paper copy of this notice of privacy practices at any time. A written request is not required.
7. Right to File a Complaint – If you believe your privacy rights have been violated, you may file a complaint with this clinic’s privacy officer, the Office of Civil Rights, or the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and Disclosure – This clinic 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 you or your child’s PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in this authorization. Please note we are required to retain records of your care.
This clinic reserves the right to revise or amend the Notice of Privacy Practices. Any revisions to this notice will be effective for any records that this clinic has created or maintained in the past or will create or maintain in the future.