Notice of Personal Health Information Practices
Revised effective October 17, 2016
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.
We keep the health and financial information of our current and former members private as required by law, accreditation standards, and our rules. This notice explains your rights. It also explains our legal duties and privacy practices. We are required by federal law to give you this notice.
We reserve the right to revise or amend our notice of privacy practices without additional notice to you. Any revision or amendment to this notice will be effective for all of your records our practice has created or maintained in the past, and for any of your records we may create or maintain in the future. Galen Medical Group, P.C. will post a copy of this Notice as amended in a prominent place in our offices and on our web site.
This notice becomes effective September 1, 2013 and amends our previous form of notice. We do not deem any current amendment to constitute a material change notice. No amendment relates to any substantive right of a Galen patient or any duty of Galen. If you have any questions about the Notice of Personal Health Information Practices, please contact our Privacy Officer at 423-308-0280 ext. 133 or by e-mail at email@example.com.
Treatment.Your health information may be used by staff members or disclosed to other healthcare professionals for the purpose of evaluating your health, diagnosing a medical condition, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment.Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
Health care operations.Your health information may be used as necessary to support the day-to-day activities and management of Galen Medical Group. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement.Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state's public health department.
Health Oversight Activities. We may disclose medical information to a health oversight agency, such as the Department of Health and Human Services, for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Family Members. We may release medical information, including mental health information, about you to a family member who is involved in your medical care without consent or authorization if the individual's involvement is related to such information. We may also give medical information, including prescription information or information concerning your appointments to friends who are involved in your care. We may also give such information to someone who helps pay for your care. In addition, we may disclose medical 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.
Business Associates. We have contracted with other entities to provide services to Galen Medical Group. When these “associates” require your personal health information in order to accomplish tasks asked of them by Galen Medical Group it will be provided to them. Examples of business associates are: billing service, collection agency, answering service, insurance service, transcription service, and computer software/hardware provider.
Research/Teaching/Training. Your personal health information may be used for the purpose of research, teaching and/or training.
Appointment Reminders. Your health information will be used by our staff to send appointment reminders to you.
Workers Compensation. We may release medical information about you for workers’ compensation or similar programs without consent or authorization. These programs provide benefits for work-related injuries or illnesses. For example, if you are injured on the job, we may release information regarding that specific injury.
Marketing. Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you. In addition, your name and address may be used to send you a newsletter about our practice and the services we offer. You may contact our Privacy Officer to request that these materials not be sent to you.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision. Special circumstances requiring your authorization. Most uses and disclosures of psychotherapy notes, health information for marketing purposes, and as part of a sale of protected health information require your authorization. Galen does not maintain psychotherapy notes, nor sell your health information. Your receipt of this notice authorizes Galen to use your health information for marketing purposes. Galen does not receive financial remuneration in exchange for communicating information to you for marketing purposes.
You have certain rights under the federal privacy standards.
The right to request restrictions on the use and disclosure of your protected health information
The right to receive confidential communications concerning your medical condition and treatment by alternative means or at alternative locations if you request, your request is reasonable, and you acknowledge that such alternative means or locations could risk the disclosure of all or part of your protected health information
The right to inspect and copy your protected health information
The right to amend or submit corrections to your protected health information
The right to receive an accounting of how and to whom your protected health information has been disclosed
The right to receive a printed copy of this notice, even if you have an electronic copy
Galen Medical Group’s Duties We are required by law to maintain the privacy of your protected health information, to provide you with this notice of our legal duties and privacy practices regarding protected health information, to notify you of a breach of any unsecured protected health information as defined by applicable regulations, and to abide by the terms of this notice then currently in effect.
Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit and on our website, unless the revisions are not significant. The revised policies and practices will be applied to all protected health information that we maintain.
Requests to Inspect Protected Health Information As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the medical records department of the Galen Medical Group office which you are a patient.
Requests for Restrictions on Protected Health Information You have a right to request us to restrict how we use and disclose your protected health information. We are not required by law to agree with your request in certain situations, including emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, disclosures to your health plan unless you pay out of pocket in full for the item or service, and any uses and disclosures described on the front page of the Notice. However, if we decide to grant your request, we are bound by our agreement.
Nondiscrimination Galen Medical Group complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Galen Medical Group will make available language assistance services free of charge.
Complaints If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: HIPAA Privacy Officer, Galen Medical Group, P.C., 4976 Alpha Lane, Hixson, TN 37343.
If you believe that your privacy rights have been violated, you should call the matter to our attention by calling the Privacy Officer at 423-308-0280 and press option 8, or by sending an e-mail to firstname.lastname@example.org or a letter describing the cause of your concern to the address provided. You may also address any complaint to the United States Secretary of Health and Human Services. You will not be penalized or otherwise retaliated against for filing a complaint.
My signature below constitutes my acknowledgement that I have been provided with a copy of the Notice of Health Information Practices. I understand Galen Medical Group, P.C. has the right to change this Notice at any time, subject to Galen's obligation to inform me of material changes.