Notice Of Privacy Practices
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 fallow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect Apri 14,.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 recieved 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 heaith 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 incled quality assessment and improvement activities, reviewing the competence qualifications of healthcare professionals, evaluating practitioner and provider performance, cooucting taining programs, accreditation, certification, licensing or credentialing activities.
To Your Family and Friends: We must disclose your health information to you, #8 described in the Patient Rights section of this Notice. We may disclose your health extant necessary 10 halp 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 of distiose health information to notify, or assist in the notification of (including identifying locating) member, representative or another 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 circumstance, we will disclose health information based on a determimation 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 judgement 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 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 avvert a serious threat to your headlth or safety or the health or safety of others.
National Security: We may disclose to millitary-authorities the health information of Armed Forces personnel under certain circumstances. We may disclose fo 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 voicemall 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 do so. (You must make a request In.writing to obtain access to your health information. You may obtain 2 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 coples and staff time. You may also request access by sending us a letter to the address at the end af this Notice. If you request copies, we will charge you $0.___for each page, $__ per hour for staff time to locate and:copy your health information, and postage if you want the copies mailed to you. if you request an altemative format, we will charge a cost-based fee for providing your health information in that format. if you prefer, we will prepare. 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 pur 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 ttie right to request that place additional restrictions on our use or disclosure of your health information. We are not required to agree 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 commiunicate with you sbout your health information by alternative means or to alternative, locations. (You must make your request in writing.) Your request must specify the alternative means of location, and provide-eatisfactory explanation how payments will be handled under the altemative 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 Notices: 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.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
* You May Refuse to Sign This Acknowedgement *