THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice describes our practices and
- Any health care professional authorized to enter information into your chart.
- Any member of a volunteer group we allow to help you while you are in the office.
- All employees, staff and other personnel.
All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or health care operations purposes described in this notice.
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the office. We need this record to provide you with quality care and
to comply with certain legal requirements. This notice applies to all of the records of your care generated by the office, whether made by office personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office or clinic.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
- Make sure that medical information that identifies you is kept private (with certain exceptions);
- Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
- Follow the terms of the notice that is currently in effect.
How We May Use and Disclose Medical Information about You
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
At Your Request
We may disclose information when requested by you. This disclosure requires a written consent.
For Treatment
We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, health care students, or other office personnel who are involved in taking care of you at the office. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. The office also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and X-rays. We also may disclose medical information about you to people outside the center who may be involved in your medical care after you leave the office, such as skilled nursing facilities, home health agencies, and physicians or other practitioners. For example, we may give your physician access to your health information to assist your physician in treating you.
For Payment
We may use and disclose medical information about you so that the treatment and services you receive at the office may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information
about surgery you received at the office so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may also provide basic information about you and your health plan, insurance company or other source of payment to practitioners outside the office who are involved in your care, to assist them in obtaining payment for services they provide to you.
For Healthcare Operations
We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run the office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many office patients to decide what additional services the office should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other office personnel for review and learning purposes. We may also combine the medical information we have with medical information from other offices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.
Appointment Reminders
We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the office.
Treatment Alternatives
We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Products and Services
We may use and disclose medical information to tell you about our healthcare-related products or services that may be of interest to you.
Fundraising Activities
We may use medical information about you, or disclose such information to a foundation related to the office, to contact you in an effort to raise money for the office and its operations. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at the office. If you do not want the office to contact you for fundraising efforts, you must notify the office administrator in writing.
Office Directory
We may include certain limited information about you in the office directory while you are a patient at the office. This information may include your name, location in the office, your general condition (e.g., good, fair, etc.) and your religious affiliation. Unless there is a specific written request from you to the contrary, this directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name. This information is released so your family, friends and clergy can visit you in the office and generally know how you are doing.
To Individuals Involved In Your Care or Payment for Your Care
We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.
Unless there is a specific written request from you to the contrary, we may also tell your family or friends your condition and that you are in the office.
In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you arrive at the emergency department either unconscious or otherwise unable to communicate, we are required to attempt to contact someone we believe can make health care decisions for you (e.g., a family member or agent under a health care power of attorney).
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT OF RECEIPT
By signing this form, you acknowledge receipt of the Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.
Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our office.
If you have any questions about our Notice of Privacy Practices, please contact the practice administrator.
I acknowledge receipt of the Notice of Privacy Practices.
