This notice describes how health information about you may be used and disclosed and how you can get access to this information.
PLEASE REVIEW THIS INFORMATION CAREFULLY
We are required by federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003 and will remain in effect until we replace it. You may request a copy of our Privacy Practice Notice at any time. For more information or additional copies of this Notice, please contact us at the telephone number listed in the Company Information section at the top of this Notice. If and when permitted by applicable, we have the right to change our privacy practices; if we do so, we will notify you in writing of these changes.
USE AND DISCLOSURES OF HEALTH INFORMATION
We are permitted, by law, to use and disclose health information about you for reasons concerning treatment, payment and healthcare operations. Examples:
Treatment: We may disclose your health information to a physician or other healthcare provider that is providing treatment or other health services to you.
Payment: We may use and disclose your health information to obtain payment for services that we provide you.
Operations: We may use and disclose your health information in connection with our healthcare operations, which include administration and planning and other tasks that help us improve that quality
Family and Friends: We may disclose your health information to a family member, relative or a friend that has been identified by you while you are present. If you are not present, professional judgment will be utilized to determine whether a disclosure is required or in your best interest. We will only disclose information that is believed to be relevant to the person’s involvement with your health care or payment related to your health care. We may also disclose your health information in order to notify such persons of your location, general condition or death.
Requirements of the Law: We may use or disclose your health information when we are required to do so by Law.
Victim of Abuse or Neglect: We may disclose your health information to authorities if reasonable belief is that you are a possible victim of abuse, neglect or domestic violence. We may disclose information to the extent necessary to avert additional serious threat to your health or safety or the health or safety of others.
Public Health Activities: We may disclose your health information to public health authorities for the purpose of preventing or controlling disease or preventing injury; to alert a person who may have been the U.S. Food and Drug Administration; to report information to a health oversight agency that is responsible for ensuring compliance with governmental rules and regulations, such as Medicare and Medicaid.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counter intelligence and other national security activities.
Appointment Reminders: We may contact you to provide you with appointment reminders, such as voice messages; including essential information such as time, location and the name of the company/provider.
Worker’s Compensation: We may use or disclose your health information to the extent necessary to comply with state laws relating to workers’ compensation.
Disclosures requiring your Authorization: For any reasons other than those listed in this notice, we may only use or disclose your health information with your written authorization. Your authorization must also be obtained prior to using your health information for any marketing activity.
YOUR RIGHTS TO YOUR PERSONAL HEALTH INFORMATION
Access to Record: You may have access to your health information, with limited exceptions. Request must be made in writing, utilizing our Record Access Request Form. We may charge a reasonable fee to compensate for time and materials.
Revocation of your Authorization: You may revoke your authorization to disclose your health information at any time. Request must be made in writing, using our Authorization Revocation form.
Restriction of Information: You may request that we place restrictions on our use or disclosure of your health information. You must make your request in writing by sending a letter that specifies the type of information to be restricted and to whom the information is to be restricted from. Requests should be sent directly to the address listed in the heading of this Notice. We will consider all requests; however are not required to agree to the request. We will respond to all such requests in writing.
Disclosure Accounting: You may request a list of instances in which we (or our business associates) Disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. You must make your request in writing by sending us a letter that specifies the type of information and the time period involved. Requests should be sent directly to the address listed in the heading of this Notice. If you request this information more than once in a 12-month period, we may charge you a reasonable fee to compensate for our time and materials.
Alternative Communication: You may request that we communicate with you about your health information by alternative means or to an alternative location. You must make your request in writing by sending a letter that specifies the alternative means or location and provide satisfactory explanation how payments will be handled under the alternative means or location you have requested. Requests should be sent directly to the address listed in the header of this Notice.
Amendment: You have the right to request that we amend your health information. You must make your request in writing by sending us a letter that explains why the information should be amended. Requests should be sent directly to the address listed in the header of this Notice. We will comply to your request unless we believe that the information to be amended is accurate and complete.
Right to Receive Paper Copy of this Notice: upon request, you may obtain a paper copy of this notice.