|
THIS NOTICE DESCRIBES HOW HEALTH
INFORMATION ABOUT YOU MAY BE USED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Our
practice is dedicated, and we are required by applicable federal and
state laws, to maintain the privacy of your health information. These
laws also require us to provide you with this Notice of our privacy practices,
and to inform you of your rights, and our obligations, concerning your
health information. We are required to follow the privacy practices
described below while this Notice is in effect. This Notice is effective
as of September 19, 2003, and will remain in effect until we replace
it.
CHANGES
TO NOTICE: We reserve the right to change this Notice and the privacy
practices described below at any time in accordance with applicable law.
Prior to making significant changes to our privacy practices, we will
alter this Notice to reflect the changes, and make the revised Notice
available to you on request. Any changes we make to our privacy practices
and/or this Notice may be applicable to health information created or
received by us prior to the date of the changes. You may request a copy
of our Notice at any time. For more information about our privacy
practices, or for additional copies of this Notice, please contact us
using the information listed at the end of this Notice.
PERMITTED
USES AND DISCLOSURES OF HEALTH INFORMATION:
A.
TREATMENT, PAYMENT, and HEALTH CARE OPERATIONS: You should be
aware that during the course of our relationship with you we will likely
use and disclose health information about you for treatment, payment, and
healthcare operations. Examples of these activities are as follows:
Treatment: We may use or disclose your health information to a physician
or other healthcare provider providing treatment to you. Payment: We may
use and disclose your health information to obtain payment for services
we provide to you. Healthcare Operations: We may use and disclose your
health information in connection with our healthcare operations.
Healthcare operations include quality assessment and improvement
activities, reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performance, and
other business operations.
B.
AUTHORIZATIONS: You may specifically authorize us to use your health
information for any purpose or to disclose your health information to
anyone, by submitting such an authorization in writing. Upon receiving an
authorization from you in writing we may use or disclose your health
information in accordance with that authorization. You may revoke an
authorization at any time by notifying us in writing. Your revocation
will not affect any use or disclosures permitted by your authorization
while it was in effect. Unless you give us a written authorization, we
cannot use or disclose your health information for any reason except those
permitted by this Notice.
C.
DISCLOSURES TO FAMILY AND PERSONAL REPRESENTATIVES: We must disclose
your health information to you, as described in the Patient Rights
section of this Notice. Such disclosures will be made to any of your
personal representatives appropriately authorized to have access and
control of your health information. We may disclose your health
information to a family member, friend or other person to the extent
necessary to help with your healthcare or with payment for your healthcare
only if authorized to do so. In the event of your incapacity or in
emergency circumstances, we will disclose health information based on a
determination using our professional judgment disclosing only health
information that is directly relevant to the person's involvement in your
healthcare.
D.
MARKETING: We will not use your health information for marketing
communications without your written authorization.
E.
USES OR DISCLOSURES REQUIRED BY LAW: We may use or disclose your
health information when we are required to do so by law, including for
public health reasons (e.g., disease reporting). In some instances, and
in accordance with applicable law, we may be required to disclose your
health information to appropriate authorities if we reasonably believe
that you are a possible victim of abuse, neglect, or domestic violence or
the possible victim of other crimes.
F.
PATIENT AND THIRD PARTY PROTECTION: Only as permitted by law, we may
disclose your health information to the extent necessary to avert a
serious threat to your health or safety or the health or safety of
others.
G. LAW
ENFORCEMENT/NATIONAL SECURITY: Under certain circumstances we may
disclose health information relating to members of the Armed Forces to
military authorities. Under certain circumstances we may also disclose
health information relating to inmates or patients to correctional
institutions or law enforcement personnel having lawful custody of those
individuals. We may disclose health information in response to judicial
proceedings and law enforcement inquiries as permitted by law and to
authorized federal officials health information required for lawful
intelligence, counterintelligence, and other national security
activities.
H.
APPOINTMENT REMINDERS: We may use or disclose your health
information to provide you with appointment reminders (such as voicemail
messages, postcards, or letters).
PATIENT
RIGHTS:
A.
ACCESS TO RECORDS:
Upon
submission of a written request to us, you have the right to review or
receive copies of your health information, with limited exceptions. You
may obtain a form to request access by using the contact information
listed at the end of this Notice. You may request that we provide copies
in a format other than photocopies and we will use the format you request
if it is readily available. We will charge you a reasonable cost-based
fee relating to the production of such copies. If you request copies, we
will charge you $0.75 for each page, a fee of no more than $10 for the
labor of copying the records, and postage if you want the copies mailed
to you. (Note: We will not charge you any fees for retrieving or handling
the information or for processing the request.) The per page dollar
amount does not apply to copies of x-rays, for which we will not charge
you more than the actual cost of reproducing the x-rays. If you request
an alternative format, we will charge a reasonable cost-based fee for
providing your health information in that format. If you prefer, we will
prepare a summary or an explanation of your health information for a fee.
Contact us using the information listed at the end of this Notice if you
are interested in receiving a summary of your information instead of
copies. If you request copies in connection with your application for social
security benefits, we will not charge you any fee.
B.
ACCOUNTING OF CERTAIN DISCLOSURES. Upon written request, you have the right
to receive a list of instances in which we or our business associates
disclosed your health information for purposes, other than treatment,
payment, healthcare operations and other activities authorized by you,
for the last 6 years, but not before April 14, 2003. If you request this
accounting more than once in a 12-month period, we may charge you a
reasonable, cost-based fee for responding to these additional
requests.
C.
RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You have the
right to request that we place additional restrictions on our use or
disclosure of your health information for treatment, payment and
healthcare operations purposes. Depending on the circumstances of your
request we may, or may not agree to those restrictions. If we do agree to
your requested restrictions we must abide by those restrictions, except
in emergency treatment scenarios. You have the right to request that we
communicate with you about your health information by alternative means
or to alternative locations (e.g., at your place of business rather than
at your home). Such requests must be made in writing, must specify the
alternative means or location, and must provide satisfactory explanation
how payments will be handled under the alternative means or location you
request.
D.
AMENDMENTS TO RECORDS: You have the right to request that we amend
your health information. Such requests must be made in writing, and must
explain why the information should be amended. We may deny your request
under certain circumstances.
E.
ELECTRONIC NOTICES. If you receive this Notice on our Web site or by electronic
mail (e-mail), you are entitled to receive this Notice in written
form.
QUESTIONS
AND COMPLAINTS
If you
want more information about our privacy practices or have questions or
concerns, please contact us. If you are concerned that we may have violated
your privacy rights, or you disagree with a decision we made or any
decisions we may make regarding the use, disclosure, or access to your
health information you may complain to us using the contact information
listed below. You also may submit a written complaint to the U.S.
Department of Health and Human Services. We will provide you with the
address to file such a complaint upon request.
We
support your right to the privacy of your health information. We will not
retaliate in any way if you choose to file a complaint with us or with
the U.S.
Department of Health and Human Services. Please direct any of your
questions or complaints to: jlarson@hdprg.com
|
