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.
OUR PLEDGE REGARDING MEDICAL INFORMATION
The privacy of your medical information is important to us. We understand that your medical information is private, and we are committed to protecting it. We create a record of the care and services that you receive at our clinic. We need this record to provide you with high-quality care and to adhere to certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.
OUR LEGAL DUTY
LAW REQUIRES US TO: Keep your medical information private, provide you with a notice describing our legal duties, privacy practices, and your right regarding your medical information, and follow the terms of the notice that is now in effect.
WE HAVE THE RIGHT TO: Change our privacy practices and the terms of this notice anytime, provided that the changes are acceptable by law. Make the changes in our privacy practices and the new term of our notice effective for all medical information that we keep counting information previously created or received before changes.
NOTICE OF CHANGE TO PRIVACY PRACTICES: Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon your request.
USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION: This section describes the different ways wherein we use and disclose medical information. We will provide an explanation for each kind of use or disclosure. Please note that not every use or disclosure will be listed.
We have listed all of the different ways we permitted to use and disclose medical information. We will not use or reveal your medical information for any purpose that is not listed below without your specific written authorization. Any specific written authorization you provide may be rescinded at any time by writing to us.
FOR TREATMENT: To provide you with medical treatment or services, we may use medical information about you. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you to assist them in treating you.
FOR PAYMENT: We may use and disclose your medical information for payment purposes. We may need to provide your health insurance information and the treatment you received at our clinic so that your health plan will pay us or repay you for any services that you have paid for. We may also tell your health plan about a treatment you’re going to receive to get approval or to find out if your plan will pay for the treatment.
FOR HEALTH CARE OPERATIONS: We may use and release your medical information for our health care operations. This might include measuring and improving quality, assessing the performance of our employees, performing training programs, and getting the accreditation and credentials that we need to serve you.
ADDITIONAL USES AND DISCLOSURES NOTIFICATION: Medical information to notify or help a family member, your personal representatives, or another person responsible for your care.
We will provide information about your location, general condition, or death. If you are present, we will get your consent if possible, before we share or give you the opportunity to refuse permission. In case of emergencies, and if you are not able to give or refuse authorization, we will share only the health information that is directly necessary for your health care, according to our professional judgment.
DISASTER RELIEF: We may share your medical information with a public, or private organization, or a person who can legally assist in disaster relief efforts.
FUNERAL DIRECTOR, CORONER, MEDICAL EXAMINER: To help them carry out their professional duties, we may share the medical information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.
SPECIALIZED GOVERNMENT FUNCTIONS: Depending on certain requirements, we may reveal or utilize health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
COURT ORDERS AND JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: We may reveal medical information in response to a court administrative order, subpoena, discovery request, or other lawful processes, under certain circumstances. Under limited circumstances, such as a court order, warrant or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. We may share the medical information of an inmate or the other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.
PUBLIC HEALTH ACTIVITIES: As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting events associated with product defects or problems, to enable product recalls, repairs or replacements to track products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.
VICTIM OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE: We may reveal medical information to appropriate authorities if we believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may provide your medical information when it is necessary to prevent a serious threat to your health or safety to others. We may provide your medical information when necessary to help law enforcement officials capture a person who had admitted to being part of a crime or has escaped from legal custody.
HEALTH OVERSIGHT ACTIVITIES: We may reveal medical information to an agency providing health oversight for oversight activities sanctioned by law, including audits, civil, administrative, criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.
YOUR INDIVIDUAL RIGHTS
YOU HAVE A RIGHT TO: Look at or get copies of your personal medical information. You may also request us to provide photocopies of your medical information. You must make your request in writing. You may get the form to request access by using the contact information listed at the end of this notice. Note that we will charge you for any copies of medical records, which is to be paid before the medical information is released.
Receive a list of all the times we, of our business associates, share your medical information for purposes other than treatment, payment and health care operations and other specified exceptions. Request that we place additional restrictions on our use or disclosure of your medical information. We are not requested to agree to these additional restrictions, but if we do, we will abide by our agreement, except in the case of an emergency.
Request that we communicate with you about your medical information by different means or to different locations. Your request that we communicate your medical information to you by different means or at different locations must be made in writing to the contact person listed at the end of this notice.
Request that we change your medical information. We may deny your request if we did not create the information you wanted to be changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted to be changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.
If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the contact person listed at the end of this notice.