This notice describes how your medical information may be used and disclosed and how you can get access to this information. Please review it carefully.
This notice of privacy practices describes how the medical provider, its medical staff members and employees may disclose your protected health information (PHI) for purposes of treatment, payment and health care operations, and for other purposes that are permitted or required by law.
I. OUR RESPONSIBILITIES:
The provider takes the privacy of your health information seriously. We are required by law to maintain the privacy of your health information and provide you with this Notice and Privacy Practices. We will abide by the terms of this Notice of Privacy Practices.
We reserve the right to change this Notice of Privacy Practices and to make any new Notice of Privacy Practices effective for all protected health information that we maintain.
II. WHAT IS “PROTECTED HEALTH INFORMATION” (PHI)?
Protected health information (PHI) is demographic and individually identifiable health information that will or may identify the patient and relates to the patient’s past, present or future physical or mental health or condition and related health care services.
III. WHAT DOES “HEALTH CARE OPERATIONS” INCLUDE?
Health care operations include activities such as communications among health care providers, conducting quality assessment and improvement activities; evaluating the qualifications, competence, and performance of health care professionals; training future health care professionals; contracting with insurance companies: conducting medical review and auditing services; compiling and analyzing information in anticipation of or for use in legal proceedings; and general administrative and business functions.
IV. HOW IS MEDICAL INFORMATION USED?
The provider uses medical records as a way of recording health information, planning care and treatment as a tool for routine health care operations. Your insurance company may request information such as procedure and diagnosis information that we are required to submit in order to bill for treatment we provide to the patient.
V. EXAMPLES OF HOW MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT OR HEALTH OPERATIONS
• Medical information may be used to justify needed patient care services, (i.e. lab tests, prescriptions, treatment protocols).
• We will use medical information to establish a treatment plan.
• We may disclose protected health information to another provider for treatment (i.e. referring physicians, specialists and other providers working with the provider).
• We may submit claims to your insurance company containing medical information and we may contact their utilization review department to receive pre-certification (prior approval for treatment).
• We may use the emergency contact information you provided to contact you if the address of record is no longer accurate.
• We may contact you to remind you of the patient’s appointment by calling you or mailing a postcard.
• We may contact you to discuss treatment alternatives or other health related benefits that may be of interest.
VI. WHY DO I HAVE TO SIGN A CONSENT FORM?
When you, the patient or the parent or guardian of a patient, sign a consent form, you are giving the provider permission to use and disclose protected health information for the purposes of treatment, payment and health care operations. This permission does not include psychotherapy notes, alcoholism and drug abuse treatment records and other privileged categories of information which require a separate authorization. You will need to sign a separate authorization to have protected health information released for any reason other than treatment, payment or health care operations.
VII. WHAT ARE PSYCHOTHERAPY NOTES?
Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are separated from the rest of the patient’s medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
VIII. WHY DO I HAVE TO SIGN A SEPARATE AUTHORIZATION FORM?
In order to release patient protected health information for any reason other than treatment, payment and health care operations, we must have an authorization signed by the patient or the parent or guardian of the patient that clearly explains how they wish the information to be used and disclosed.
IX. CAN I CHANGE MY MIND AND REVOKE AN AUTHORIZATION?
You may change your mind and revoke an authorization, except (1) to the extent that we have relied on the authorization up to that point, (2) the information is needed to maintain the integrity of the research study, or (3) if the authorization was obtained as a condition of obtaining insurance coverage. All requests to revoke an authorization should be in writing.
X. WHEN IS MY AUTHORIZATION / CONSENT NOT REQUIRED?
The law requires that some information may be disclosed without your authorization in the following circumstances:
• In case of an emergency
• When there are communication or language barriers
• When required by law
• When there are risks to public health
• To conduct health oversight activities
• To report suspected abuse or neglect
• To specified government regulatory agencies
• In connection with judicial or administrative proceedings
• For law enforcement purposes
• To coroners, funeral directors, and for organ donation
• In the event of a serious threat to health or safety
XI. YOUR PRIVACY RIGHTS
The 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.
1. You have the right to inspect and copy your health information.
This means you may inspect and obtain a copy of your PHI that is contained in a “designated record set” for so long as we maintain the PHI. A designated record set contains medical and billing records and any other record the provider uses in making decisions about you health care. You may not however, 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 certain PHI is subject to laws that prohibit access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Clinic Administrator if you have questions about access to your medical record.
2. You have the right to request a restriction of your health information.
This means you may ask us to restrict or limit the medical information we use or disclose for the purposes of treatment, payment or health care operations. The provider is not required to agree to a restriction that you may request. We will notify you if we deny your request. If we do agree to the request restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by contacting our Clinic Administrator.
3. You have the right to request to receive confidential communications by alternative means or at alternative locations.
We will accommodate reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the requests must be made in writing to our Clinic Administrator.
4. You have the right to request amendments to your health information.
This means you may request an amendment of PHI 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, you have the right to file a statement of disagreement with our Clinic Administrator and we may prepare a rebuttal to your statement and will provide you with a copy of this rebuttal. If you wish to amend your PHI, please contact our Clinic Administrator. Requests for amendment must be in writing.
5. You have the right to receive an accounting of disclosures of your health information.
You have the right to request an accounting of certain disclosures of your PHI made by the provider. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed by signing an authorization form, disclosures to family or friends involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Clinic Administrator. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years.
6. You have the right to receive a paper copy of this Notice of Privacy Practices.
XII. WHAT IF I HAVE A QUESTION / COMPLAINT?
If you have questions regarding your privacy rights, please contact the provider before agreeing and proceeding with your checkout.