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.
UNDERSTANDING YOUR HEALTH RECORD
A record is made each time you visit a hospital, physician, or other health care provider. Your symptoms, examination and test results, diagnosis, treatment, and a plan for future care are recorded. This information is most often referred to as your “health record” or “medical record,” and serves as a basis for planning your care and treatment. It also serves as a means of communication among any and all other health professionals who may contribute to your care. Understanding what information is retained in your record and how that information may be used, will help you to ensure its accuracy and enable you to relate to who, what, when, where, and why others may be allowed access to your health information. This effort is being made to assist you in making informed decisions before authorizing the disclosure of your medical information to others.
UNDERSTANDING YOUR HEALTH INFORMATION RIGHTS
Your health record is the physical property of the health care practitioner or facility that compiled it, but the content is about you, and therefore, belongs to you. You have the right to request restrictions on certain uses and disclosures of your information and to request amendments to your health record. Your rights include being able to review or obtain a paper copy of your health information and to be given an account of all disclosures. You may also request communications of your health information be made by alternative means or to alternative locations. Other than activity that has already occurred, you may revoke any further authorizations to use or disclose your health information.
This office is required to maintain the privacy of your health information and to provide you with notice of our legal commitment and privacy practices with respect to the information we collect and maintain about you. This office is required to abide by the terms of this notice and to notify you if we are unable to grant your requested restrictions or reasonable desires to communicate your health information by alternative means or to alternative locations. This office reserves to right to change its practices and effect new provisions that enhance the privacy standards of all patient medical information. In the event that changes are made, this office will notify you at the current address provided on your medical file. If applicable, this office will post changes on our web site that provides information about our customer service and/or benefits. Other than for reasons described in this notice, this office agrees not to use or disclose your health information without your authorization.
TO RECEIVE ADDITIONAL INFORMATION OR REPORT A PROBLEM
If you believe your privacy rights have been violated, you have to right to file a complaint with this office by contacting the individual above, or by contacting the Secretary of Health and Human Services, with no fear of retaliation by this office.
YOUR HEALTH INFORMATION WILL BE USED FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
Treatment – Information obtained by your health care practitioner in this office will be recorded in your medical record and used to determine the course of treatment that should work best for you. This consists of your physician recording his/her own expectations and those of others involved in providing your care, such as specialty physicians, nurse practitioners, or therapists.
Payment – Your health care information will be used in order to receive payment for services rendered by this office. A bill may be sent to either you or a third-party payer with accompanying documentation that identifies you, your diagnosis, procedures performed, and supplies used.
Health Care Operations – The medical staff in this office will use your health information to assess the care you received and the outcome of your case compared to others like it. Your information may be reviewed for risk management or quality improvement purposes in our efforts to continually improve the quality and effectiveness of the care and services we provide.
UNDERSTANDING OUR OFFICE POLICY FOR SPECIFIC DISCLOSURES
Business Associates – Some or all of your health information may be subject to disclosure through contracts for services to assist this office in providing health care. For example, it may be necessary to obtain specialized assistance to process certain laboratory tests or radiology images. To provide your health information, we require these Business Associates to follow the same standards held by this office through terms detailed in a written agreement.
Notification – Your health record may be used to notify or assist family members, personal representatives, or other persons responsible for your care to enhance your well-being or your whereabouts.
Communications with Family – Using best judgment, a family member or close personal friend identified by you may be given information relevant to your care and/or recovery.
Food and Drug Administration (FDA) – This office is required by law to disclose health information to the FDA related to any adverse effects of food, supplements, products, or product defects for surveillance to enable product recalls, repairs, or replacements.
Worker’s Compensation – This office will release information to the extent authorized by law in matters of worker’s compensation.
Public Health – This office is required by law to disclose health information to public health and/or legal authorities charged with tracking reports of birth and morbidity. This office is further required by law to report communicable disease, injury, or disability.
Correctional Facilities – This office will release information on incarcerated individuals to correctional agents or institutions for the necessary welfare of the individual or for the health and safety of other individuals. The rights outlined in this Notice of Privacy Practices will not be extended to incarcerated individuals.
Law Enforcement – (1) Your health information will be disclosed for law enforcement purpose as required under state law or in response to a valid subpoena. (2) Provisions of federal law permit the disclosure of your health information to appropriate health oversight agencies, public health authorities, or attorneys in the event that a staff member or business associate of this office believes in good faith that there has been unlawful conduct or violations of professional or clinical standards that may endanger one or more patients, workers, or the general public.
RESPECT OTHER PATIENT’S PRIVACY
If you are found accessing another patient’s medical record or any other documents with personal health information without the consent of the patient and permission from the facility, you will be asked to leave the clinic and not return.
NOTICE OF PRIVACY PRACTICES AVAILABILITY
The terms described in this notice will be available in the waiting area. A hard copy will be provided at your request.
Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations.
I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.
I understand that this information serves as a basis for planning my care and treatment; a means of communication among the many health professionals who contribute to my care; a source of information for applying my diagnosis and information to my bill; a means by which a third-party payer can verify that services billed were actually provided; and as a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided.
I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.
If you would like to request restrictions to the use or disclosure of your health information, please inform us of your request at any visit.