|
This notice describes how health
information about you may be used and disclosed and how
you can get access to this information. Please review it
carefully. |
|
THE PRIVACY OF YOUR
HEALTH INFORMATION IS IMPORTANT TO US. |
|
OUR LEGAL DUTY |
|
We are
required by applicable federal and state law to
maintain the privacy of your health information. We
are also required to give you this Notice
about our Privacy Practices, our legal
duties, and your rights concerning your health
information. We must follow the Privacy Practices
that are described in this Notice while it is
in effect. This Notice takes effect
04/01/2003, and will remain in effect until we
replace it. |
|
We
reserve the right to change our Privacy Practices
and the terms of this Notice at any time,
provided such changes are permitted by applicable
law. We reserve the right to make the changes in our
Privacy Practices and the new terms of our
Notice effective for all health information that
we maintain, including health information we created
or received before we made the changes. Before we
make a significant change in our Privacy
Practices, we will change this Notice and
make the new Notice available upon request. |
|
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. |
|
USES AND
DISCLOSURES OF HEALTH INFORMATION |
|
We
use and disclose health information about you
for treatment, payment, and healthcare
operations. For example: |
|
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,
conducting training programs, accreditation,
certification, licensing or credentialing
activities. |
|
Your Authorization: In addition
to our use of your health information for
treatment, payment or healthcare operations,
you may give us written authorization to use
your health information or to disclose it to
anyone for any purpose. If you give us an
authorization, you may revoke it in writing
at any time. 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
described in this Notice. |
|
To Your
Family and Friends: We must
disclose your health information to you, as
described in the Patient Rights
section of this Notice. 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, but only
if you agree that we may do so. |
|
Persons Involved In Care:
We may use or disclose health information to
notify, or assist in the notification of
(including identifying or locating) a family
member, your personal representative or
another person responsible for your care, of
your location, your general condition, or
death. If you are present, then prior to use
or disclosure of your health information, we
will provide you with an opportunity to
object to such uses or disclosures. In the
event of your incapacity or 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. We will also use our
professional judgment and our experience
with common practice to make reasonable
inferences of your best interest in allowing
a person to pick up filled prescriptions,
medical supplies, x-rays, or other similar
forms of health information. |
|
Marketing
Health-Related Services: We
will not use your health information for
marketing communications without your
written authorization. |
|
Required by Law:
We may use or disclose your health
information when we are required to do
so by law. |
|
Abuse or Neglect:
We may 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. 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. |
|
National Security: We may
disclose to military authorities the
health information of Armed Forces
personnel under certain circumstances.
We may disclose to authorized federal
officials health information required
for lawful intelligence,
counterintelligence, and other national
security activities. We may disclose to
correctional institution or law
enforcement official having lawful
custody of protected health information
of inmate or patient under certain
circumstances. |
|
Appointment
Reminders: We may use or
disclose your health information to
provide you with appointment
reminders (such as voicemail
messages, postcards, or letters). |
|
Access:
You have the right to look at or get
copies of your health information,
with limited exceptions. You may
request that we provide copies in a
format other than photocopies. We
will use the format you request
unless we cannot practicably do so.
(You must make a request in writing
to obtain access to your health
information. You may obtain a form
to request access by using the
contact information listed at the
end of this Notice. We will
charge you a reasonable cost-based
fee for expenses such as copies and
staff time. You may also request
access by sending us a letter to the
address at the end of this Notice.
If you request copies, we will
charge you for each page, for each
hour of staff time to locate and
copy your health information, and
postage if you want the copies
mailed to you. If you request an
alternative format, we will charge a
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
for a full explanation of our fee
structure.) |
|
Disclosure
Accounting: 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 certain other
activities, 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. |
|
Restriction: You have the
right to request that we place
additional restrictions on our use
or disclosure of your health
information. We are not required to
agree to these additional
restrictions, but if we do, we will
abide by our agreement (except in an
emergency). |
|
Alternative
Communication: You have
the right to request that we
communicate with you about your
health information by alternative
means or to alternative locations.
{You must make your request in
writing.} Your request must
specify the alternative means or
location, and provide satisfactory
explanation how payments will be
handled under the alternative means
or location you request. |
|
Amendment:
You have the right to request that
we amend your health information.
(Your request must be in writing,
and it must explain why the
information should be amended.) We
may deny your request under certain
circumstances. |
|
Electronic Notice:
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
Christina at our office location
referenced below. |
|
If you are
concerned that we may have
violated your Privacy Rights, or
you disagree with a decision we
made about access to your health
information or in response to a
request you made to amend or
restrict the use or disclosure
of your health information or to
have us communicate with you by
alternative means or at
alternative locations, you may
complain to us using the contact
information listed at the end of
this Notice. 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 your
complaint with the U.S.
Department of Health and Human
Services upon request. |
|
We support your right to the
privacy of your health
information. We will no
retaliate in any way if you
choose to file a complaint with
us or with the U.S. Department
of Health and Human Services. |
|