Notice of Privacy Practices
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 practice uses and discloses health information about you for
treatment, to obtain payment for treatment, for administrative purposes, and to
evaluate the quality of care that you receive.
This notice describes our privacy practices. We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. You can request a paper copy of this notice, or any revised notice, at any time (even if you have allowed us to communicate with you electronically). For more information about this notice or our privacy practices and policies, please contact the person listed at the end of this document.
A. Treatment, Payment, Health Care Operations
Treatment
We are permitted to use and disclose your medical information to those
involved in your treatment. For example,
the physician in this practice is a specialist.
When we provide treatment we may request that your primary care
physician share your medical information with us. Also, we may provide your primary care
physician information about your particular condition so that he or she can
appropriately treat you for other medical conditions, if any.
Payment
We are permitted to use and disclose your medical information to bill
and collect payment for the services we provide to you. For example, we may
complete a claim form to obtain payment from your insurer or HMO. That form
will contain medical information, such as a description of the medical services
provided to you, that your insurer or HMO needs to approve payment to us.
Health Care Operations
We are permitted to use or disclose your medical information for the
purposes of health care operations, which are activities that support this
practice and ensure that quality care is delivered. For example, we may engage the services of a
professional to aid this practice in its compliance programs. This person will review billing and medical
files to ensure we maintain our compliance with regulations and the law. Or we may ask another physician to review
this practice’s charts and medical records to evaluate our performance so that
we may ensure that this practice provides only the best health care.
B. Disclosures That Can Be Made Without Your
Authorization
There are situations in which we are permitted to disclose or use your medical information without your written authorization or an opportunity to object. In other situations, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and disclosures. However, any revocation will not apply to disclosures or uses already made or that rely on that authorization.
Public Health, Abuse or
Neglect, and Health Oversight
We may disclose your medical information for public health
activities. Public health activities are
mandated by federal, state, or local government for the collection of
information about disease, vital statistics (like births and death), or injury
by a public health authority. We may disclose
medical information, if authorized by law, to a person who may have been
exposed to a disease or may be at risk for contracting or spreading a disease
or condition. We may disclose your
medical information to report reactions to medications, problems with products,
or to notify people of recalls of products they may be using.
Because
We may disclose your medical information to a health oversight agency
for those activities authorized by law. Examples of these activities are
audits, investigations, licensure applications and inspections, which are all
government activities undertaken to monitor the health care delivery system and
compliance with other laws, such as civil rights laws.
Legal Proceedings and Law
Enforcement
We may disclose your medical information in the course of judicial or
administrative proceedings in response to an order of the court (or the
administrative decision-maker) or other appropriate legal process. Certain requirements must be met before the
information is disclosed.
If asked by a law enforcement official, we may disclose your medical
information under limited circumstances provided:
§
The information
is released pursuant to legal process, such as a warrant or subpoena;
§
The information
pertains to a victim of crime and you are incapacitated;
§
The information
pertains to a person who has died under circumstances that may be related to
criminal conduct;
§
The information
is about a victim of crime and we are unable to obtain the person’s agreement;
§
The information
is released because of a crime that has occurred on these premises; or
§
The information
is released to locate a fugitive, missing person, or suspect.
We also may release information if we believe the disclosure is
necessary to prevent or lessen an imminent threat to the health or safety of a
person.
Workers’ Compensation
We may disclose your medical information as required by workers’
compensation law.
Inmates
If you are an inmate or under the custody of law enforcement, we may
release your medical information to the correctional institution or law
enforcement official. This release is
permitted to allow the institution to provide you with medical care, to protect
your health or the health and safety of others, or for the safety and security
of the institution.
Military, National Security
and Intelligence Activities, Protection of the President
We may disclose your medical information for specialized governmental functions such as
separation or discharge from military service, requests as necessary by
appropriate military command officers (if you are in the military), authorized
national security and intelligence activities, as well as authorized activities
for the provision of protective services for the president of the United
States, other authorized government officials, or foreign heads of state.
Research, Organ Donation,
Coroners, Medical Examiners, and Funeral Directors
When a research project and its privacy protections have been approved
by an institutional review board or privacy board, we may release medical
information to researchers for research purposes. We may release medical information to organ procurement organizations for
the purpose of facilitating organ, eye, or tissue donation if you are a
donor. Also, we may release your medical
information to a coroner or medical examiner to identify a deceased person or a
cause of death. Further, we may release
your medical information to a funeral director when such a disclosure is
necessary for the director to carry out his duties.
Required by Law
We may release your medical information when the disclosure is required
by law.
C. Your Rights Under Federal Law
The U. S. Department of Health and Human Services created regulations
intended to protect patient privacy as required by the Health Insurance
Portability and Accountability Act (HIPAA).
Those regulations create several privileges that patients may
exercise. We will not retaliate against
patients who exercise their HIPAA rights.
Requested Restrictions
You may request that we restrict or limit how your protected health
information is used or disclosed for treatment, payment, or health care
operations. We do NOT have to agree to this restriction, but if we do agree, we
will comply with your request except under emergency circumstances.
You also may request that we limit disclosure to family members, other
relatives, or close personal friends who may or may not be involved in your
care.
To request a restriction, submit the following in writing: (a) the
information to be restricted, (b) what kind of restriction you are requesting
(i.e., on the use of information, disclosure of information, or both), and (c)
to whom the limits apply. Please send
the request to the address and person listed at the end of this document.
Receiving Confidential
Communications by Alternative Means
You may request that we send communications of protected health
information by alternative means or to an alternative location. This request must be made in writing to the
person listed below. We are required to
accommodate only reasonable requests.
Please specify in your correspondence exactly how you want us to
communicate with you and, if you are directing us to send it to a particular
place, the contact/address information.
Inspection and Copies of
Protected Health Information
You may inspect and/or copy health information that is within the
designated record set, which is information that is used to make decisions
about your care.
We may ask that a narrative of that information be provided rather than
copies. However, if you do not agree to
our request, we will provide copies.
We can refuse to provide some of the information you ask to inspect or
ask to be copied for the following reasons:
§
The information is psychotherapy notes.
§
The information reveals the identity of a person who provided information
under a promise of confidentiality.
§
The information is subject to the Clinical Laboratory Improvements
Amendments of 1988.
§
The information has been compiled in anticipation of litigation.
We can refuse to provide access to or copies of some information for other reasons, provided that we arrange for a review of our decision on your request. Any such review will be made by another licensed health care provider who was not involved in the prior decision to deny access.
HIPAA permits us to charge a reasonable cost-based fee.
Amendment of Medical
Information
You may request an amendment of your medical information in the
designated record set. Any such request
must be made in writing to the person listed at the end of this document. We will respond within 60 days of your
request. We may refuse to allow an
amendment for the following reasons:
§
The
information wasn’t created by this practice or the physicians in this practice.
§
The information is not part of the designated record set.
§
The information is not available for inspection because of an
appropriate denial.
§
The information is accurate and complete.
Even if we refuse to allow an amendment, you are permitted to include a patient statement about the information at issue in your medical record. If we refuse to allow an amendment, we will inform you in writing.
If we
approve the amendment, we will inform you in writing, allow the amendment to be
made and tell others that we now have the corrected information.
Accounting of Certain
Disclosures
HIPAA privacy regulations permit you to request, and us to provide, an
accounting of disclosures that are other than for treatment, payment, health
care operations, or made via an authorization signed by you or your representative.
Please submit any request for an accounting to the person at the end of this
document. Your first accounting of disclosures (within a 12-month period) will
be free. For additional requests within
that period we are permitted to charge for the cost of providing the list. If there is a charge we will notify you, and
you may choose to withdraw or modify your request before any costs are
incurred.
D. Appointment Reminders, Treatment
Alternatives, and Other Benefits
We may contact you by (telephone, mail, or both) to provide appointment
reminders, information about treatment alternatives, or other health-related
benefits and services that may be of interest to you.
E. Complaints
If
you are concerned that your privacy rights have been violated, you may contact
the person listed below. You may also
send a written complaint to the U. S. Department of Health and Human
Services. We will not retaliate against
you for filing a complaint with us or the government.
F. Our Promise to You
We are required by law and regulation to protect the privacy of your
medical information, to provide you with this notice of our privacy practices
with respect to protected health information, and to abide by the terms of the
notice of privacy practices in effect.
G. Questions and Contact Person for Requests
If you have any questions or want to make a request pursuant to the
rights described above, please contact:
Privacy Officer
White Rock Orthopedic Association
(214) 660-0505 Telephone
(214) 660-4484 Facsimile
admin@whiterockorthopedic.com
This notice is effective July 13, 2005.
Acknowledgement
of Review of
Notice
of Privacy Practices
I have reviewed this
office’s Notice of Privacy Practices, which explains how my medical
information will be used and disclosed.
I understand that I am entitled
to receive a copy of this document.
_________________________________________
Signature of Patient or Personal Representative
_______________________________
Date
_________________________________________
Name of Patient or Personal Representative
_________________________________________
Description of Personal Representative’s Authority