Uses and
Disclosures of Protected Health Information Based Upon Your Written
Consent
You will be asked
by your physician to sign a consent form. Once you have consented to
use and disclosure of your protected health information for treatment,
payment and health care operations by signing the consent form, your
physician will use or disclose your protected health information as
described in this Section 1. Your protected health information may be
used and disclosed by your physician, our office staff and others outside
of our office that are involved in your care and treatment for the purpose
of providing health care services to you. Your protected health information
may also be used and disclosed to pay your health care bills and to
support the operation of the physician’s practice.
Following are examples
of the types of uses and disclosures of your protected health care information
that the physician’s office is permitted to make once you have
signed our consent form. These examples are not meant to be exhaustive,
but to describe the types of uses and disclosures that may be made by
our office once you have provided consent.
Treatment:
We will use and disclose your protected health information to provide,
coordinate, or manage your health care and any related services. This
includes the coordination or management of your health care with a third
party that has already obtained your permission to have access to your
protected health information. For example, we would disclose your protected
health information, as necessary, to a home health agency that provides
care to you. We will also disclose protected health information to other
physicians who may be treating you when we have the necessary permission
from you to disclose your protected health information. For example,
your protected health information may be provided to a physician to
whom you have been referred to ensure that the physician has the necessary
information to diagnose or treat you.
In addition, we
may disclose your protected health information from time-to-time to
another physician or health care provider (e.g., a specialist or laboratory)
who, at the request of your physician, becomes involved in your care
by providing assistance with your health care diagnosis or treatment
to your physician.
Payment:
Your protected health information will be used, as needed, to obtain
payment for you health care services. This may include certain activities
that your health insurance plan may undertake before it approves or
pays for the health care services we recommend for you such as; making
a determination of eligibility or coverage for insurance benefits, reviewing
services provided to you for medical necessity, and undertaking utilization
review activities. For example, obtaining approval for a hospital stay
may require that your relevant protected health information be disclosed
to the health plan to obtain approval for the hospital admission.
Healthcare
Operations: We may use or disclose, as needed, your protected
health information in order to support the business activities of your
physician’s practice. These activities include, but are not limited
to, quality assessment activities, employee review activities, training
of medical students, licensing, marketing activities, and conducting
or arranging for other business activities.
For example, we
may disclose your protected health information to medical school students
that see patients at our office. In addition, we may use a sign-in sheet
at the registration desk where you will be asked to sign your name and
indicate your physician. We may also call you by name in the waiting
room when your physician is ready to see you. We may use or disclose
your protected health information, as necessary, to contact you to remind
you of your appointment.
We will share your
protected health information with third party “business associates”
that perform various activities (e.g., billing, transcription services)
for the practice. Whenever an arrangement between our office and a business
associate involves the use or disclosure of your protected health information,
we will have a written contract that contains terms that will protect
the privacy of your protected health information.
We may use or disclose
your protected health information, as necessary, to provide you with
information about treatment alternatives or other health-related benefits
and services that may be of interest to you. We may also use and disclose
your protected health information for other marketing activities. For
example, your name and address may be used to send you a newsletter
about our practice and the services we offer. We may also send you information
about products or services that we believe may be beneficial to you.
You may contact our Privacy Contact to request that these materials
not be sent to you.
We may use or disclose
your demographic information and the dates that you received treatment
from your physician, as necessary, in order to contact you for activities
supported by our office. If you do not want to receive these materials,
please contact our Privacy Contact and request that these fundraising
materials not be sent to you.
Uses and
Disclosures of Protected Health Information Based upon Your Written
Authorization
Other uses and disclosures
of your protected health information will be made only with your written
authorization, unless otherwise permitted or required by law as described
below. You may revoke this authorization, at any time, in writing, except
to the extent that your physician or the physician’s practice
has taken an action in reliance on the use or disclosure indicated in
the authorization.
Other Permitted
and Required Uses and Disclosures That May Be Made With Your Consent,
Authorization or Opportunity to Object
We may use and disclose
your protected health information in the following instances. You have
the opportunity to agree or object to the use or disclosure of all or
part of your protected health information. If you are not present or
able to agree or object to the use or disclosure of the protected health
information, then your physician may, using professional judgment, determine
whether the disclosure is in your best interest. In this case, only
the protected health information that is relevant to your health care
will be disclosed.
Others Involved
in Your Healthcare: Unless you object, we may disclose to a member of
your immediate family, spouse, caretaker or any other person you identify
your protected health information that directly relates to that person’s
involvement in your health care. If you are unable to agree or object
to such a disclosure, we may disclose such information as necessary
if we determine that it is in your best interest based on our professional
judgment. We may use or disclose protected health information to notify
or assist in notifying a family member, personal representative or any
other person that is responsible for your care of your location, general
condition or death. Finally, we may use or disclose your protected health
information to an authorized public or private entity to assist in disaster
relief efforts and to coordinate uses and disclosures to family or other
individuals involved in your health care.
Emergencies:
We may use or disclose your protected health information in an emergency
treatment situation. If this happens, your physician shall try to obtain
your consent as soon as reasonably practicable after the delivery of
treatment. If your physician or another physician in the practice is
required by law to treat you and the physician has attempted to obtain
your consent but is unable to obtain your consent, he or she may still
use or disclose your protected health information to treat you.
Communication
Barriers: We may use and disclose your protected health information
if your physician or another physician in the practice attempts to obtain
consent from you but is unable to do so due to substantial communication
barriers and the physician determines, using professional judgment,
that you intend to consent to use or disclosure under the circumstances.
Other Permitted
and Required Uses and Disclosures That May Be Made Without Your Consent,
Authorization or Opportunity to Object
We may use or disclose
your protected health information in the following situations without
your consent or authorization. These situations include:
Required
By Law: We may use or disclose your protected health information
to the extent that the use or disclosure is required by law. The use
or disclosure will be made in compliance with the law and will be limited
to the relevant requirements of the law. You will be notified, as required
by law, of any such uses or disclosures.
Public Health:
We may disclose your protected health information for public health
activities and purposes to a public health authority that is permitted
by law to collect or receive the information. The disclosure will be
made for the purpose of controlling disease, injury or disability. We
may also disclose your protected health information, if directed by
the public health authority, to a foreign government agency that is
collaborating with the public health authority.
Communicable
Disease: We may disclose your protected health information,
if authorized by law, to a person who may have been exposed to a communicable
disease or may otherwise be at risk of contracting or spreading the
disease or condition.
Health Oversight:
We may disclose protected health information to a health oversight agency
for activities authorized by law, such as audits, investigations, and
inspections. Oversight agencies seeking this information include government
agencies that oversee the health care system, government benefit programs,
other government regulatory programs and civil rights laws.
Abuse or
Neglect: We may disclose your protected health information
to a public health authority that is authorized by law to receive reports
of child abuse or neglect. In addition, we may disclose your protected
health information if we believe that you have been a victim of abuse,
neglect or domestic violence to the governmental entity or agency authorized
to receive such information. In this case, the disclosure will be made
consistent with the requirements of applicable federal and state laws.
Food and
Drug Administration: We may disclose your protected health
information to a person or company required by the Food and Drug Administration
to report adverse events, product defects or problems, biologic product
deviations, track products; to enable product recalls; to make repairs
or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings:
We may disclose protected health information in the course of any judicial
or administrative proceeding, in response to an order of a court or
administrative tribunal (to the extent such disclosure is expressly
authorized), in certain conditions in response to a subpoena, discovery
request or other lawful process.
Law Enforcement:
We may also disclose protected health information, so long as applicable
legal requirements are met, for law enforcement purposes. These law
enforcement purposes include (1) legal processes and otherwise required
by law, (2) limited information request for identification and location
purposes, (3) pertaining to victims of a crime, (4) suspicion that death
has occurred as a result of criminal conduct, (5) in the event that
a crime occurs on the premises of the practice, and (6) medical emergency
(not on the Practice’s premises) and it is likely that a crime
has occurred.
Coroners,
Funeral Directors, and Organ Donation: We may disclose protected
health information to a coroner or medical examiner for identification
purposes, determining cause of death or for the coroner or medical examiner
to perform other duties authorized by law. We may also disclose protected
health information to a funeral director, as authorized by law, in order
to permit the funeral director to carry out their duties. We may disclose
such information in reasonable anticipation of death. Protected health
information may be used and disclosed for cadaveric organ, eye or tissue
donation purposes.
Research:
We may disclose your protected health information to researchers when
their research has been approved by an institutional review board that
has reviewed the research proposal and established protocols to ensure
the privacy of your protected health information.
Criminal
Activity: Consistent with applicable federal and state laws,
we may disclose your protected health information, if we believe that
the use or disclosure is necessary to prevent or lessen a serious and
imminent threat to the health or safety of a person or the public. We
may also disclose protected health information if it is necessary for
law enforcement authorities to identify or apprehend an individual.
Military
Activity and National Security: When the appropriate conditions
apply, we may use or disclose protected health information of individuals
who are Armed Forces personnel (1) for activities deemed necessary by
appropriate military command authorities; (2) for the purpose of a determination
by the Department of Veterans Affairs of your eligibility for benefits,
or (3) to foreign military authority if you are a member of that foreign
military services. We may also disclose your protected health information
to authorized federal officials for conducting national security and
intelligence activities, including for the provision of protective services
to the President or others legally authorized.
Workers’
Compensation: Your protected health information may be disclosed
by us as authorized to comply with workers’ compensation laws
and other similar legally-established programs.
Inmates:
We may use or disclose your protected health information if you are
an inmate of a correctional facility and your physician created or received
your protected health information in the course of providing care to
you.
Required
Uses and Disclosure: Under the law, we must make disclosures
to you and when required by the Secretary of the Department of Health
and Human Services to investigate or determine our compliance with the
requirements of Section 164.500 et. Seq.
Following is a
statement of your rights with respect to your protected health information
and a brief description of how you may exercise these rights.
You have
the right to inspect and obtain a copy of your protected health information.
This means you may inspect and obtain a copy of protected health information
about you that is contained in a designated record set for as long as
we maintain the protected health information. A “designated record
set” contains medical and billing records and any other records
that your physician and the practice uses for making decisions about
you. You may not make alterations to your permanent medical record.
Under federal law,
however, you may not inspect or copy the following records; psychotherapy
notes; information compiled in reasonable anticipation of, or use in,
a civil, criminal, or administrative action or proceeding, and protected
health information that is subject to law that prohibits access to protected
health information. Depending on the circumstances, a decision to deny
access may be reviewable. In some circumstances, you may have a right
to have this decision reviewed. Please contact our Privacy Contact if
you have questions about access to your medical record.
You have
the right to request a restriction of your protected health information.
This means you may ask us not to use or disclose any part of your protected
health information for the purposes of treatment, payment or healthcare
operations. You may also request that any part of your protected health
information not be disclosed to family members or friends who may be
involved in your care or for notification purposes as described in this
Notice of Privacy Practices. Your request must state the specific restriction
requested and to whom you want the restriction to apply.
Your physician is
not required to agree to a restriction that you may request. If your
physician believes it is in your best interest to permit use and disclosure
of your protected health information, your protected health information
will not be restricted. If your physician does agree to the requested
restriction, we may not use or disclose your protected health information
in violation of that restriction unless it is needed to provide emergency
treatment. With this in mind, please discuss any restriction you wish
to request with your physician. You may request a restriction by contacting
our Privacy Contact, Hether Buhler.
You have
the right to request to receive confidential communications from us
by alternative means or at an alternative location. We will
accommodate reasonable request. We may also condition this accommodation
by asking you for information as to how payment will be handled or specification
of an alternative address or other method of contact. We will not request
an explanation from you as to the basis for the request. Please make
this request in writing to our Privacy Contact.
You may
have the right to have your physician amend your protected health information.
This means you may request an amendment of protected health information
about you in a designated record set for as long as we maintain this
information . In certain cases, we may deny your request for an amendment.
If we deny your request for amendment, you have the right to file a
statement of disagreement with us and we may prepare a rebuttal to your
statement and will provide you with a copy of any such rebuttal. Please
contact our Privacy Contact to determine if you have questions about
amending your medical record. Please make your request to amend your
protected health information in writing to our Privacy Contact.
You have
the right to receive an accounting of certain disclosures we have made,
if any, of your protected health information. This right applies
to disclosures for purposes other than treatment, payment or healthcare
operations as described in this Notice of Privacy Practices. It excludes
disclosures we may have made to you, to family members or friends involved
in your care, or for notification purposes. You have the right to receive
specific information regarding these disclosures that occurred after
April 14, 2003. You may request a shorter timeframe. The right to receive
this information is subject to certain exceptions, restrictions and
limitations.
You have
the right to obtain a paper copy of this notice from us, upon request,
even if you have agreed to accept this notice electronically.
