1. The Practice may use and disclose protected health
information for treatment, payment and healthcare operations. Examples
of these include, but are not limited to, requested preschool, sports
physicals, referral to nursing homes, foster care homes, home health
agencies and/or referral to other providers for treatment. Payment
examples include, but are not limited to, insurance companies (for
claims including coordination of benefits with other insurers) and
collection agencies. Healthcare operations include, but are not limited
to, internal quality control and assurance including auditing of
records.
2. The Practice is permitted or required to use or disclose protected
health information without the individual’s written consent
or authorization in certain circumstances. Two examples of such are
for public health requirements
and court orders.
3. The Practice will not make any other use or disclosure of a patient’s
protected health information without the individual’s written authorization.
Such authorization may be revoked at any time. Revocation must be written.
4. The Practice will abide by the terms of this notice currently in effect
at the time of the disclosure.
5. The Practice reserves the right to change the terms of its notice and to
make new notice provisions effective for all protected health information that
it maintains. The Practice will provide each patient with a copy of any revisions
to its Notice of Information Practices at the time of their next visit, or
at their last known address if there is a need to use or disclose any protected
health information of the patient. Copies may also be obtained at any time
at our office.
6. Any patient, guardian or personal representative has the right to object
to the use of their health information for directory purposes.
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7. Any patient, guardian or personal representative
has the right to inspect and obtain copies of their medical record.
8. Any patient, guardian or personal representative has the right to request
amendments be made to their medical record.
9. Any patient, guardian or personal representative has the right to request
a six-year accounting of all disclosures of their medical record. The history
will be provided within 60 days of the request, and a reasonable charge may be
assessed for any copies after the first request in a 12-month period.
10. Any patient, guardian or personal representative has the right to request
restrictions as to how their health information may be used or disclosed to carry
out treatment, payment or healthcare operations. The Practice is not required
to agree to the restrictions requested, but if The Practice does agree, The Practice
must abide by those restrictions.
11. Any person/patient may file a complaint to The Practice and to the Secretary
of Health and Human Services if they believe their privacy rights have been violated.
To file a
complaint with The Practice, please contact the Privacy Officer at The Practice
address and/or phone number. All complaints will be addressed, and the results
will be reported
to the Privacy Officer.
12. It is the policy of The Practice that retaliatory action will be made against
any
individual who submits or conveys a complaint of suspected or actual non-compliance
of the privacy standards.The effective date of this notice is April 14, 2003.
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