Privacy Notice

Effective 7/1/13
 

Revised 1/1/25

This Notice describes how medical information about you may be used and disclosed, and how you can access this information. Please review it carefully.

Protected health information (PHI) about you is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice   Specifically, PHI is information about you, including demographic information (e.g., name, address, phone, etc.) that may identify you and relate to your past, present, or future physical or mental health condition and related healthcare services.

Our practice is legally required to maintain the confidentiality of your PHI and follow specific rules when using or disclosing this information. This Notice describes your rights to access and control your PHI and explains how we follow applicable laws when using or disclosing your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations, and other purposes permitted or required by law.

Your Rights Under The Privacy Rule

The following is a statement regarding your PHI and rights under the Privacy Rule. Please feel free to discuss any questions with our staff.

You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices   We are required by law to follow the terms of this Notice   We reserve the right to change the Notice's terms and make the new Notice provisions effective for all PHI we maintain   We will provide you with a copy of our current Notice if you call our office and request that a copy be sent to you in the mail, or ask for one at your next appointment   The Notice will also be posted in a conspicuous location in the practice, and if such is maintained, on the practice's website.

You have the right to authorize other uses and disclosures. This means we will only use or disclose your PHI as described in this Notice, unless you authorize other use or disclosure in writing   For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intend to sell your PHI   You may revoke an authorization at any time, in writing, except that your healthcare provider, or our practice, has acted in reliance on the use or disclosure indicated in the authorization.

You have the right to request an alternative means of confidential communication   This means you have the right to ask us to contact you about medical matters using an alternative method (i.e., email, fax, telephone), and/or to a destination (i.e., cell phone number, alternative address, etc.) designated by you   You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/phone number that we have on file   We will follow all reasonable requests.

You can inspect and obtain a copy of your PHI*. This means you may submit a written request to inspect or obtain a copy of your complete health record, or to direct us to disclose your PHI to a third party   If your health record is maintained electronically, you will also have the right to request a copy in electronic format   We have the right to charge a reasonable, cost-based fee for paper or electronic copies as established by federal guidelines   We must provide you with access to your records within 30 days of your written request unless an extension is necessary   In such cases, we will notify you of the reason for the delay and the expected date when the request will be fulfilled.

You have the right to request a restriction of your PHI*. This means you may ask us, in writing, not to use or disclose any part of your protected health information for treatment, payment, or healthcare operations   If we agree to the requested restriction, we will abide by it, except in emergencies when the data is needed for your treatment   In some instances, we may deny your request for a restriction   You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket   We are not permitted to deny this exact type of requested restriction.

You have the right to request an amendment to your protected health information (PHI).* You may submit a written request to amend your PHI for as long as we maintain it. In some instances, we may deny your request.

You have the right to request disclosure accountability*. You may submit a written request for a listing of disclosures we have made of your PHI to entities or persons outside of our practice, except for those made upon your request or for purposes of treatment, payment, or healthcare operations. We will not charge a fee for the first accounting provided in 12 months.

You have the right to receive a privacy breach notice if the practice discovers a breach of your unsecured PHI and determines through a risk assessment that notification is required; you have the right to receive written notification.

*  If you have questions regarding your privacy rights or would like to submit any of the written requests described above, don't hesitate to contact our Privacy Manager. Contact information is provided at the bottom of the following page.

How We May Use or Disclose Protected Health Information

We can provide examples of uses and disclosures of your protected health information. These examples are not meant to be exhaustive but to describe possible uses and disclosures.

Treatment - We may use and disclose your PHI to provide, coordinate, or manage your healthcare and related services   This includes coordinating or managing your healthcare with a third party involved in your care and treatment   For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions   We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment. 

Payment—Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you, such as determining eligibility or coverage for insurance benefits.

Healthcare Operations—We may use or disclose your PHI, as needed, to support our practice's business activities. This includes, but is not limited to, business planning and development, quality assessment and improvement, medical review, legal services, auditing functions, and patient safety activities.

Special Notices—We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment   We may also contact you by phone or other means to provide results from exams or tests, information that describes or recommends treatment alternatives regarding your care, or information about health-related benefits and services offered by our office.

We may contact you regarding fundraising activities, but you have the right to opt out of receiving further fundraising communications. Each fundraising notice will include instructions for opting out.

Health Information Organization—The practice may use a health information organization or another organization to facilitate the electronic exchange of information for treatment, payment, or healthcare operations.

To Others Involved in Your Healthcare - Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your PHI directly related to that person's involvement in your healthcare   Suppose you cannot agree or object to such a disclosure   In that case, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment   We may use or disclose PHI to notify or assist in notifying a family member, personal representative, or any other person responsible for your care, of your general condition or death   Suppose you are not present or able to agree or object to the use or disclosure of PHI (e.g., in a disaster relief situation)   In that case, your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest   In this case, only the necessary PHI will be disclosed.

Other Permitted and Required Uses and Disclosures - We are also permitted to use or disclose your PHI without your written authorization, or providing you an opportunity to object, for the following purposes:  if required by state or federal law; for public health activities and safety issues (e.g. a product recall); for health oversight activities; in cases of abuse, neglect, or domestic violence; to avert a serious threat to health or safety; for research purposes; in response to a court or administrative order, and subpoenas that meet specific requirements; to a coroner, medical examiner or funeral director; to respond to organ and tissue donation requests; to address worker's compensation, law enforcement and specific other government requests, and for specialized government functions (e.g., military, national security, etc); with respect to a group health plan, to disclose information to the health plan sponsor for plan administration; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

Privacy Complaints

You have the right to complain to or directly to the Department of Health and Human Services Secretary if you believe we have violated your privacy rights. We will not retaliate against you for filing a complaint.

You may ask questions about your privacy rights, file a complaint, or submit a written request (for access, restriction, or amendment of your PHI or to obtain disclosure accountability) by notifying our Privacy Manager at 317-621-9000.