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Notice of Privacy Practices Form (1010)
Please review this form carefully. This form describes how and when medical information about you may be disclosed. At the Internal Medicine Clinic, we are committed to preserving the privacy of your personal health information.
“Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health conditions and the health care services that were provided to treat those conditions.
This Notice of Privacy Practices describes how we may use and disclose your protected health information in order to carry out treatment, payment, health care, and any other purposes required by law. The Notice of Privacy Practices also describes your rights to access and control your protected health information.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices.
You will be asked to sign an acknowledgement form that documents your receipt of the Notice of Privacy Practices. Your signature also acknowledges that your agreement to read and understand this notice. Your physician will use or disclose your protected health information as described in Section 1.
Your protected health information may be used by and disclosed to your physician, our office staff, and other people outside of our office who are involved in your care and treatment. This information is disclosed for the purpose of providing the best possible health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice. Here are some examples of the types of uses and disclosures of your protected health care information that our office is permitted to make. These examples are not meant to be exhaustive.
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any other services related to your health care. We may disclose health information about you to doctors, nurses, technicians, office staff, or other professional personnel who are involved your care.
For example, if we have referred you to another physician, we may disclose your protected health information to that physician to ensure that he or she has all of the necessary information to diagnose and treat you appropriately.
From time to time, we may disclose your protected health information to another physician or health care provider, such as a specialist or a laboratory. This information, which is provided at your physician’s request, will help them provide health care diagnoses and treatment.
As needed, your protected health information may be used to obtain payment for your health care services. Your health insurance plan may undertake certain activities before it approves or pays for the health care services we recommend. These activities may include (but are not limited to) making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you to determine their medical necessity, and undertaking utilization review activities.
When necessary, we may use or disclose your protected health information to support our practice’s business activities. These activities may include, but are not limited to, quality assessment, employee review, licensing, and conducting or arranging for other business activities.
For example, at the registration desk, we may ask you to sign in when you arrive. We may also call you by name in the waiting room when the physician is ready to see you.
We may contact you with appointment reminders. If you do not wish to receive these types of communication, please advise us in writing. If you do not wish to use or disclosure your protected health information for this purpose, please advise us in writing.
We may share your protected health information with third party business associates who perform various activities for the practice, such as billing and transcription services. Whenever an arrangement between our office and a business associate requires the disclosure of your protected health information, we have a written contract with that third party to protect the privacy of your protected health information.
When necessary, we may use or disclose your protected health information to inform you about treatment alternatives or other relevant health-related benefits and services.
For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Officer to request that these materials not be sent to you.
Any other uses and disclosures of your protected health information will be made only with your written authorization unless otherwise permitted or required by law as described below. You may revoke this authorization at any time by providing us written notice. Your revocation will be effective when we receive it, but it will not apply to any uses or disclosures that occurred prior to our receipt of your revocation. If you do revoke your authorization, we will not be permitted to use or disclose your protected health information for purposes of treatment, payment, or health care operations, and we may therefore be unable to continue providing you with health care treatment and services.
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information.
If you are not present, or if you are physically unable to agree or object to the disclosure of your protected health information, the physician may determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Unless you object, we may disclose your protected health information to a family, close friend, or any other person you identify, if your protected health information directly relates to that person’s involvement in your health care. For example, we may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
If you are not present, or if you are physically unable to agree or object to the disclosure of your protected health information, the physician may determine whether the disclosure is in your best interest.
We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician will try to obtain your consent as soon as possible after the emergency treatment. If your physician or another physician in the practice is required by law to treat you and the physician is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.
Notice of Privacy Practices Form (1010)
Please review this form carefully. This form describes how and when medical information about you may be disclosed. At the Internal Medicine Clinic, we are committed to preserving the privacy of your personal health information.
We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers. Using professional judgment, the physical will determine if you intend to consent to use or disclosure under the circumstances.
We may use or disclose your protected health information in the following situations without your consent or authorization.
We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician will try to obtain your consent as soon as possible after the emergency treatment. If your physician or another physician in the practice is required by law to treat you and the physician is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.
We will disclose health information about you when required by federal, state, or local law.
We may use and disclose your protected health information to a public health authority when authorized by law. These reports are intended to prevent or control disease, injury, or disability.
If authorized by law, we may disclose your protected health information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, licensure, and inspections.
We may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse or neglect. In addition, we may disclose your protected health information to the appropriate governmental entity or agency if we believe that you have been a victim of abuse, neglect, or domestic violence. In the case of suspected abuse or neglect, the disclosure will be consistent with the requirements of applicable federal and state laws.
We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, or biologic product deviations, to track products and enable product recalls, to make repairs or replacements, or to conduct post-marketing surveillance.
We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, licensure, and inspections.
We may disclose protected health information to a coroner or medical examiner for identification purposes, to determine the cause of death, or for the coroner or medical examiner to perform other duties authorized by law. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.
When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel. We may disclose this information for activities deemed necessary by appropriate military command authorities, for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or to foreign military authority if you are a member of foreign military services. We may also disclose your protected health information to authorized federal officials conducting national security and intelligence activities, including the provision of protective services to the President or others legally authorized.
Your protected health information may be disclosed by us as authorized to comply with Workers’ Compensation laws and other similar legally-established programs.
Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
What follows is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice use for making decisions about your health care. Under federal law, however, you may not inspect or copy information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and you may not inspect of copy protected health information subject to laws that prohibits access to them. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical records.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes, as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest, the use or disclosure of your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information unless it is necessary to provide emergency treatment.
Please consult your physician before requesting any restrictions. You may request a restriction by completing a Request for Disclosure Restriction (Form 1014) and obtaining Internal Medicine Clinic’s agreement for those restrictions.
You have the right to request confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may request only to be contacted by postal mail or at a work phone number. Contact our Privacy Officer, complete a Request for Disclosure Restriction (Form 1014), and obtain agreement by Internal Medicine Clinic for such restrictions. You have the right to ask your physician to amend your protected health information, should you believe that this information is incorrect or incomplete. You may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer to determine if you have questions about amending your medical record.
You have the right to receive an account of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices. This right excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. A Request for Accounting Disclosure Form must be completed and a specific time period (not to exceed 6 years) must be specified. You may request a shorter time frame. The first request in a twelve-month period will be free. You will be charged for any additional requests. The right to receive this information is subject to certain exceptions, restrictions, and limitations. You have the right to receive a paper copy of this notice from us, upon your request, at any time.
We reserve the right to revise this notice and to make the revised notice effective for medical information we already have about you as well as any information about you that we may receive in the future. We will post a summary of the current notice in the office with its effective date in the top right corner. You are, at any time, entitled to a copy of the notice that is currently in effect.
If you believe that your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.
You may contact Nancy Austin (330) 364-7551 for further information about the complaint process.
Patient Information
Patient Privacy
Please review this form carefully. This form describes how and when medical information about you may be disclosed. At the Internal Medicine Clinic, we are committed to preserving the privacy of your personal health information.
Protected Health Information
Notice of Privacy Practices
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices.
You will be asked to sign an acknowledgement form that documents your receipt of the Notice of Privacy Practices. Your signature also acknowledges that your agreement to read and understand this notice. Your physician will use or disclose your protected health information as described in Section 1.
Your protected health information may be used by and disclosed to your physician, our office staff, and other people outside of our office who are involved in your care and treatment. This information is disclosed for the purpose of providing the best possible health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice. Here are some examples of the types of uses and disclosures of your protected health care information that our office is permitted to make. These examples are not meant to be exhaustive.
How we may use and disclose your Protected Health Information
Treatment
For example, if we have referred you to another physician, we may disclose your protected health information to that physician to ensure that he or she has all of the necessary information to diagnose and treat you appropriately.
From time to time, we may disclose your protected health information to another physician or health care provider, such as a specialist or a laboratory. This information, which is provided at your physician’s request, will help them provide health care diagnoses and treatment.
Payment
Healthcare Operations
Appointment Reminders
Business Associates
Health-Related Benefits and Services
Uses and Disclosures of Protected Health Information Based On Your Written Authorization
Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent
Others Involved in Your Healthcare
If you are not present, or if you are physically unable to agree or object to the disclosure of your protected health information, the physician may determine whether the disclosure is in your best interest.
Emergencies
Patient Privacy
Please review this form carefully. This form describes how and when medical information about you may be disclosed. At the Internal Medicine Clinic, we are committed to preserving the privacy of your personal health information.
Communication Barriers
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization, or Opportunity to Object
Emergencies
Required By Law
Public Health
Communicable Diseases
Health Oversight
Abuse or Neglect
Food and Drug Administration
Legal Proceedings
Law Enforcement
Coroners, Funeral Directors, and Organ Donation
Military Activity and National Security
Workers’ Compensation
Required Uses and Disclosures
Your Protected Health Information Rights
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice use for making decisions about your health care. Under federal law, however, you may not inspect or copy information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and you may not inspect of copy protected health information subject to laws that prohibits access to them. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical records.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes, as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest, the use or disclosure of your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information unless it is necessary to provide emergency treatment.
Please consult your physician before requesting any restrictions. You may request a restriction by completing a Request for Disclosure Restriction (Form 1014) and obtaining Internal Medicine Clinic’s agreement for those restrictions.
You have the right to request confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may request only to be contacted by postal mail or at a work phone number. Contact our Privacy Officer, complete a Request for Disclosure Restriction (Form 1014), and obtain agreement by Internal Medicine Clinic for such restrictions. You have the right to ask your physician to amend your protected health information, should you believe that this information is incorrect or incomplete. You may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer to determine if you have questions about amending your medical record.
You have the right to receive an account of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices. This right excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. A Request for Accounting Disclosure Form must be completed and a specific time period (not to exceed 6 years) must be specified. You may request a shorter time frame. The first request in a twelve-month period will be free. You will be charged for any additional requests. The right to receive this information is subject to certain exceptions, restrictions, and limitations. You have the right to receive a paper copy of this notice from us, upon your request, at any time.
Changes to this notice
Complaints
You may contact Nancy Austin (330) 364-7551 for further information about the complaint process.