 |
 |
 |
 |
|
|
NOTICE
OF PRIVACY PRACTICES
Effective Date of Notice: April 14, 2003 |
| 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. |
| We are required by law to maintain
the privacy of your Protected Health Information (“PHI”).
PHI is personal information about you, including demographic
information that we collect from you, that may be used to
identify you and relates to your past, present or future physical
or mental health or condition, including treatment and payment
for the provision of healthcare. This Notice explains our
legal duties and privacy practice with regard to your PHI.
We are required by federal law to provide you with a copy
of this Notice and to abide by the terms of this Notice. Accordingly,
we will ask you to sign a statement acknowledging that we
have provided you with a copy of the Notice. If you have elected
to receive a copy electronically, you still have the right
to obtain a paper copy upon request. We reserve the right
to change the terms of this Notice at any time. The change
may be retroactive and cover PHI that we received or created
prior to the revision. If we do change the Notice, a copy
of the new Notice will be posted in the waiting room and on
our website, if any. We will provide you with a copy of the
revised Notice upon your request. |
|
| You have six rights as a patient
of Fox Rehabilitation Services, P.C.: |
| 1. |
The right to consider and sign
an authorization for a non-authorized use. The law only allows
us to use or disclose your PHI in certain circumstances, as
explained more fully below. If we need to make a use or disclosure
that does not fall into one of those exceptions–including
the disclosure of immunization records to schools or results
of work physicals to employers– we will ask you to sign
an authorization. If we do not have a valid authorization
on file specifically authorizing the proposed use or disclosure,
then we will not make that use or disclosure. You may revoke
an authorization at any time in writing, but the revocation
will not apply to uses or disclosures we have already made
in reliance on your original authorization. |
| 2. |
The right to access your PHI. You
have a right to access and receive a copy, summary or explanation
of your PHI. If you want to exercise this right, please ask
one of our employees for a Request to Access Medical Records
form. You will need to complete this for and submit it to
us. This right does not extend to psychotherapy notes, information
compiled in reasonable anticipation of legal action and confidential
information relating to certain lab tests. We have the right
to deny you access, but you will be notified of the reason
for denial and be given the right to have the denial reviewed
under certain circumstances. |
| 3. |
The right to request restrictions
on certain uses and disclosures. You may request restrictions
of uses or disclosures of your PHI when it is used to carry
out your treatment, obtain payment for your treatment or perform
healthcare operations of our practice. You must request the
restriction before we have used or disclosed the relevant
information. We are not required to agree to the restriction,
and we have the right to decide not to accept the restriction
and not to treat you. |
| 4. |
The right to receive confidential
communications. You may request that we make confidential
communications to you by an alternative means or at an alternative
location. The request must be in writing, but we will not
ask for an explanation from you. We will accommodate reasonable
requests, but we may condition the accommodation on information
as to how payment, if any, will be handled and specification
of an alternative address or other method of contact. |
| 5. |
The right to amend PHI. You have
the right to ask us to amend your PHI. If you want to exercise
this right, please ask one of our employees for a Request
for Amendment of Medical Records form. You will need to complete
this form, provide a reason for the request and submit it
to us. We have the right deny your request for amendment,
if we determine that your record was not created by us, is
not maintained by us, would not be available for access, or
is accurate and complete. Your records will not be changed
or deleted as a result of our granting your request, but the
amendment will be attached to your record and its existence
noted in your record as necessary. (Note: use of this procedure
is not necessary for routine changes to your demographic information,
such as address, phone number, etc.) |
| 6. |
The right to receive an accounting. You have
the right to receive an accounting of our uses and disclosures
of your PHI. If you want to exercise this right, please ask
one of our employees for a Request for Accounting form. You
will need to complete this form and submit it to us. The accounting
does not have to list disclosures made (i) to carry out treatment,
payment and healthcare operations; (ii) to you; (iii) pursuant
to an authorization; (iv) for national security or intelligence
purposes; (v) to correctional institutions or law enforcement
personnel or (vi) that occurred prior to April 14, 2003. (Note:
compliance with this right is time-consuming, and so we reserve
the right to charge you a fee if you request more than one
accounting in a twelve-month period.) |
|
| We intend to limit the disclosure
of your PHI to that necessary for Treatment, Payment and Operations: |
| • |
Treatment refers to specific sharing and use
of your PHI relating to your direct care by our employees,
including consulting other professionals and the use of disease
management programs. For example, we will disclose your PHI
to another health care professional or a testing facility
to whom you have been referred for care or for assistance
with treatment. |
| • |
Payment refers to specific sharing and use
of your PHI for purposes of obtaining payment for our treatment
of you, including billing and collection activities, related
data processing and disclosure to consumer reporting agencies.
For example, your PHI will be disclosed on forms we submit
to your insurance plan for us to receive payment. |
| • |
Operations refers to specific sharing and use
of your PHI necessary for our administrative and technical
operations, within the limitations imposed by professional
ethics. Permissible activities would include, but are not
limited to, quality assessment, employee review, student training
and other business activities. For example, we might need
to disclose your PHI to a medical student as part of the educational
process. |
| We
will not permit the following disclosures without your written
authorization, and your refusal to provide such authorization
will not affect our duty to treat you: |
| • |
Marketing. |
| • |
To your employer, except where necessary for
provision of care or payment purposes (for example, if your
employer is self-insured). |
| • |
Disclosures outside our offices, unless for
treatment, payment or operations. |
| • |
For research purposes, unless certain safeguards
are taken. |
| We
may make disclosures in certain situations as required by
law, even without your written authorization. These situations
include, but are not limited to: |
| • |
If all identifying information is removed so
your identity cannot be ascertained from the information disclosed,
i.e., on a completely anonymous basis. |
| • |
When required by law, for example, public health
reporting purposes or to a person who may be affected by a
communicable disease. |
| • |
To your employer, if we are providing care
to you at your employer’s request as part of an evaluation
of a work-related illness or injury, or medical surveillance
of your workplace. |
| • |
Pursuant to a warrant or court order. |
| • |
For health oversight purposes, for example,
an investigation of our practice for purposes unrelated to
your treatment. |
| • |
To a public health authority designated to
receive notification of abuse or neglect. |
| • |
To the U.S. Food and Drug Administration, in
the event of an adverse event. |
| • |
To law enforcement for certain purposes. |
| • |
Related to a judicial or administrative proceeding,
provided certain circumstances are met. |
| • |
For military activity or national secuvrity. |
| • |
For worker’s compensation purposes. |
| |
| To facilitate the
smooth and efficient operation of our practice, we engage
in certain practices and policies that you should understand.
You can avoid any of the following practices by discussing
your concerns with us and working out an alternative: |
| • |
We contact our patients by telephone (including
leaving a message on an answering machine or voice mail) or
mail to provide appointment reminders or routine test results. |
| • |
We use sign-in sheets and call out names in
our waiting room to manage patient flow. |
| • |
Our staff will conduct routine discussions
at our front desk with patients. |
| • |
We may contact our patients by telephone or
mail to provide information about treatment alternatives or
other health-related benefits and services that may be of
interest. |
| • |
We may use your name and address to send you
a newsletter about our practice and the services we offer. |
| • |
We may disclose your PHI to a member of your
family or a close friend that relates directly to that person’s
involvement in your healthcare. |
| You should also be
aware of the following policies regarding our uses and disclosures
of your PHI. You cannot avoid these uses and disclosures,
but you should discuss any questions or concerns you might
have with us: |
| • |
We share PHI with third-party “business
associates” that perform various functions for us (for
example, billing and transcription), but we have written contracts
with those entities containing terms that require the protection
of your PHI. |
| • |
We will disclose your PHI to your personal
representative(s), if any, unless we determine in the exercise
of our professional judgment that such disclosure should not
be made. |
| |
| If you have any questions
about this Notice, the matters discussed herein or anything
else related to our privacy policy, please feel free to ask
for an appointment with our Privacy and Security Officer. |
| You may complain to
us or the United States Secretary of Health and Human Services
if you believe your privacy rights have been violated. To
complain to the Secretary, your complaint must be in writing,
name us, describe the acts or omissions believed to be in
violation of your privacy rights and be filed within 180 days
of when you knew or should have known that the act or omission
occurred. |
| You can file a complaint
with us by asking for a Complaint Reporting Form. We will
not retaliate against you for filing a complaint. If you want
further information about the complaint process, please talk
to our Privacy and Security Officer. |
