Notice Regarding
Privacy of
Personal
Health Information
NOTICE REGARDING PRIVACY OF PERSONAL HEALTH
INFORMATION
For Family Center for Allergy and
Asthma
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.
Federal regulations developed
under the Health Insurance
Portability and Accountability Act (HIPAA) require that the practice provide
you with this Notice Regarding Privacy of Personal Health Information. The Notice describes (1) how the practice may use and disclose your
protected health information, (2) your rights to access and control your protected health
information in certain circumstances, and (3) the practices’ duties and contact
information.
I. Protected Health Information
"Protected health
information" is health information created or received by your health care
provider that contains information that may be used to identify you, such as
demographic data. It includes written
or oral health information that relates to your past, present or future
physical or mental health; the provision of health care to you; and your past,
present, or future payment for health care.
II. The Use and Disclosure
of Protected Health Information in Treatment, Payment, and Health Care
Operations
Your
protected health information may be used and disclosed by the practice in the
course of providing treatment, obtaining payment for treatment, and conducting
health care operations. Any disclosures
may be made in writing, electronically, by facsimile, or orally. The practice may also use or disclose your
protected health information in other circumstances if you authorize the use or
disclosure, or if state law or the HIPAA privacy regulations authorize the use
or disclosure.
Treatment. The practice may use and disclose your protected health
information in the course of providing or managing your health care as well as
any related services. For the purpose
of treatment, the practice may coordinate your health care with a third party. For
example, the practice may disclose your protected health information to a pharmacy to fulfill a
prescription for asthma medication, to an X-ray facility to order an X-ray, or
to another physician who is administering your allergy shots, which we
prepared. In addition, the practice may disclose protected health
information to other physicians or health care providers for treatment
activities of those other providers.
Payment. When needed, the practice will use or
disclose your protected health information to obtain payment for its services. Such
uses or disclosures may include disclosures to your health insurer to get approval for a recommended treatment or to determine
whether you are eligible for benefits or whether a particular service is
covered under your health plan. When obtaining payment for your health care, the
practice may also disclose your
protected health information to your insurance company to demonstrate the
medical necessity of the care or for utilization review when required to do so
by your insurance company. Finally,
the practice may also disclose your protected health information to another
provider where that provider is involved
in your care and requires the information to obtain payment.
Operations.
The practice may use or disclose
your protected health information when needed
for the practice’s health care operations for the purposes of management or
administration of the practice and of offering quality health care
services. Health care operations may
include: (1) quality evaluations and improvement activities; (2) employee review
activities and training programs; (3) accreditation,
certification, licensing, or credentialing activities; (4) reviews and
audits such as compliance reviews, medical reviews, legal services, and maintaining compliance programs; and (5) business
management and general administrative activities. For instance, the practice may
use, as needed, protected health information of patients to review their treatment
course when making quality assessments regarding allergy care or
treatment. In addition, the practice may disclose your
protected health information to another provider or health plan for their health care operations.
Other Uses and Disclosures. As part of treatment, payment, and healthcare operations, the practice
may also use or disclose your protected health information to: (1) remind you of an appointment including the
leaving of appointment reminder information on your telephone answering machine;
or leaving a message with an individual at the point of contact phone number
provided ; (2) sending reminder notices to the address provided informing you
to make an appointment (3) inform you of potential treatment alternatives or
options; or (4) inform you of
health-related benefits or services that may be of interest to you.
II. Additional Uses and Disclosures Permitted Without Authorization
or An Opportunity to Object
In addition to treatment, payment, and
health care operations, the practice may use or disclose your protected health
information without your permission or authorization in certain circumstances,
including:
When Legally Required. The
practice will comply with any Federal, state or local law that requires it to
disclose your protected health information.
When There Are Risks to Public Health. The practice
may disclose your protected health
information for public health purposes, including to, as permitted or required
by law:
(1) Prevent,
control, or report disease, injury, or disability;
(2) Report vital events such as birth or
death;
(3) Conduct public health surveillance,
investigations, and interventions;
(4) Collect or report
adverse events and product defects, track FDA regulated products, enable
product recalls, repairs, or replacements, and conduct post marketing
surveillance;
(5) Notify a person who has been exposed to a
communicable disease or who may be at risk of contracting or spreading a
disease; and
(6) Report to an employer information about
an individual who is a member of the workforce.
To Report Abuse,
Neglect Or Domestic Violence. As
required or authorized by law or with the patient’s agreement, the practice may inform government authorities if it is
believed that a patient is the victim of abuse, neglect or domestic violence.
To Conduct Health
Oversight Activities.
The practice may disclose your protected health information to a health oversight
agency for use in (1) audits; (2) civil,
administrative, or criminal investigations, proceedings or actions; (3)
inspections; (4) licensure or
disciplinary actions; or (5) other necessary oversight activities as permitted
by law. However, if you are the subject
of an investigation, the practice will not disclose protected health
information that is not directly
related to your receipt of health
care or public benefits.
For Judicial And Administrative
Proceedings. The practice may disclose your protected health information for any
judicial or administrative
proceeding if the disclosure is expressly authorized by an order of a court or
administrative tribunal as expressly authorized by such order or a signed authorization is provided.
For Law Enforcement Purposes. The practice may disclose your protected health information to a law enforcement official for law enforcement
purposes when:
(1) Required
by law to report of certain types of physical injuries;
(2) Required by court order, court-ordered
warrant, subpoena, summons, or similar process;
(3) Needed to identify or
locate a suspect, fugitive, material witness, or missing person;
(4) Needed to report a crime in an
emergency situation.
(5) You are the victim of a
crime in specific limited instances; and
(6) Your death is
suspected by the practice to be the result of criminal conduct.
To Coroners, Funeral Directors, and for
Organ Donation.
The practice may disclose protected health information to a coroner or
medical examiner for the purpose of (1) identification, (2) determination of cause of death, or (3) performance of the coroner
or medical examiner’s other duties as authorized by law. In
addition, as permitted by law, the practice may disclose protected health
information, including when death is reasonably anticipated, to a funeral director to enable the funeral director to
carry out his or her duties. Protected health information may also be
used and disclosed for the purpose of cadaveric organ, eye or tissue donation.
For Research
Purposes.
The practice may use or disclose
your protected health information for research if such use or disclosure
has been approved by an institutional
review board or privacy board that has examined the research proposal and the
research protocols which maintain the privacy of your protected health
information.
To Prevent or Diminish A Serious and
Imminent Threat To Health Or Safety.
If in good faith the practice
believes that use or disclosure of your protected health information is necessary to prevent or diminish a serious and
imminent threat to your health or safety or to the health and safety of the public, the practice may use or
disclose your protected health information as permitted under law and
consistent with ethical standards of conduct.
For Specified Government Functions. As authorized by the HIPAA privacy regulations,
the practice may use or disclose your protected health information to
facilitate specified government functions relating to military and veterans
activities, national security and intelligence activities, protective services
for the President and others, medical suitability determinations, correctional
institutions, and law enforcement custodial situations.
For Worker's Compensation. The practice
may disclose your protected health information to comply with worker's
compensation laws or similar programs.
III. Uses and Disclosures Permitted With An Opportunity to Object
Subject to your
objection, the practice may disclose your protected health information (1) to a
family member or close personal friend if the disclosure is directly relevant to
the person's involvement in your care or payment related to your care; or (2)
when attempting to locate or notify family members or others involved
in your care to inform them of your location, condition or death. The practice will inform you orally or in
writing of such uses and disclosures of your protected health information as
well as provide you with an opportunity to object in advance. Your agreement or objection to the uses and
disclosures can be oral or in writing.
If you do not object to these disclosures, the practice is able to infer from the
circumstances that you do not object, or the practice determines, in its
professional judgment, that it is in your best interests for the practice to
disclose information that is directly relevant to the person's involvement with
your care, then the practice may disclose your protected health
information. If you are incapacitated
or in an emergency situation, the practice may exercise its professional
judgment to determine if the disclosure is in your best interests and, if such
a determination is made, may only disclose information directly relevant to
your health care.
IV. Uses and Disclosures Authorized
by You
Other than the circumstances described above, the practice
will not disclose your health information unless you provide written
authorization. You may revoke your authorization in writing at any time except to the
extent that the practice have taken action in reliance upon the authorization.
V. Your Rights
You
have certain rights regarding your protected health information under the HIPAA
privacy regulations. These rights
include:
The right to inspect and copy
your protected health information. For as
long as the practice holds your protected health information, you may
inspect and obtain a copy of such information included in a designated record set. A "designated record set" contains
medical and billing records as well as any other records that your physician
and the practice uses to make decisions regarding the services provided to
you. The practice may deny your
request to inspect or copy your protected health information if the practice determines in its professional judgment that the access requested is
likely to endanger your life or
safety or that of another person, or that it is likely to cause substantial
harm to another person referred to in
the information. You have the right to
request a review of this decision.
In addition,
you may not inspect or copy certain records by law, including: (1) information
compiled in reasonable anticipation of, or for use in, a civil,
criminal, or administrative action or proceeding; and (2) protected health
information that is subject to a law that prohibits access to protected health
information. You may have the right to have a
decision to deny access reviewed in some situations.
You must submit a written request to
the practice’s Privacy Officer to inspect and copy your health
information. The practice may charge you a fee for the costs of copying, mailing, or other costs incurred by the
practice in complying with your
request. Please contact our Privacy Officer if you have questions about access
to your medical record at the number
given on the last pages of this Notice.
The right to request a restriction on uses and
disclosures of your protected health information.
You may request that the practice not
use or disclose specific sections of your
protected health information for the purposes of treatment, payment, or health
care operations. Additionally, you may request that the
practice not disclose your health information to family members or friends who may be involved in your
care or for notification purposes as described in this Notice. In
your request, you must specify the scope of restriction requested as well as the individuals for which you want the
restriction to apply. Your request
should be directed to the practice’s Privacy Officer.
The practice may chose to deny your
request for a restriction, in which case the practice will notify you of its
decision. Once the practice agrees to the
requested restriction, the practice may not violate that restriction unless use or disclosure of the
relevant information is needed to provide emergency treatment. The practice may terminate the agreement to a restriction in some instances.
The
right to request to receive confidential communications from the practice by
alternative means or at an alternative location.
You have the right to request that the practice communicates with you through
alternative means or at an alternative location. The practice will make every effort to comply with reasonable
requests. However, the practice
may condition its compliance by asking you for information regarding the
procurement of payment or specific information regarding an alternative address
or other method of contact. You are not required to provide an explanation for
your request. Requests should be made in
writing to the practice’s Privacy Officer.
The
right to request an amendment of your protected health information. During the time that the practice holds your
protected health information, you may request an amendment of your information
in a designated record set. The practice may deny your request in some instances. However, should the practice deny your request for amendment, you have the right to file a statement of
disagreement with the practice. In
turn, the practice may develop a rebuttal
to your statement. If it does so, the
practice will provide you with a copy of the rebuttal. Requests
for amendment must be submitted in writing to the practice’s Privacy
Officer. Your written request must supply a reason to support the requested
amendments.
The right to request
an accounting of certain disclosures.
You have the right to request an accounting of the practice’s disclosures of your
protected health information made for
purposes other than treatment, payment or health care operations as described in this Notice. The practice is not required to account for disclosures (1) which you
requested, (2) which you authorized by signing
an authorization form, (3) for a facility directory, (4) to friends or family members involved in your care, and (5) certain
other disclosures the practice is permitted to make without your authorization. The request for an accounting must be made
in writing to our Privacy Officer and
should state the time period for which you wish the accounting to include up to
a six-year period. The practice is not required to provide an
accounting for disclosures that take place prior to April 14, 2003. The
practice will not charge you for the first accounting you request of any
12-month period. Subsequent accountings may require a fee based on the practice’s
reasonable costs for compliance of the request.
The right to obtain a paper copy
of this Notice. The practice will provide a separate paper copy of this Notice upon request even if you
have already been given a copy of it or have agreed to review it
electronically.
VI. The Practice’s Duties
The practice is required to ensure the privacy of your
health information and to provide you with
this Notice of your rights and the practice’s duties and procedures regarding
your privacy. The practice must abide by the terms of this Notice, as may be
amended periodically. The practice
reserves the right to change the
terms of this Notice and to make the new Notice provisions effective for all protected
health information that the practice collects and maintains. If the practice alters its Notice, the
practice will provide a copy of the revised Notice through regular mail or in-person contact.
VII. Complaints
If you believe that your privacy
rights have been violated, you have the
right to relate complaints to the practice and to the Secretary of the
Department of Health and Human Services. You may provide complaints to
the practice verbally or in writing. Such complaints should be directed to the
practice's Privacy Officer. The
practice encourages you to relate any concerns you may have regarding the privacy of your information and you will not be retaliated against in any way for filing a complaint.
VIII. Contact
Person
The practice's
contact person regarding the practice’s duties and your rights under the HIPAA privacy regulations is the Privacy
Officer. The Privacy Officer can provide information
regarding issues related to this Notice by request. Complaints to the practice should be directed to the Privacy
Officer at the following address:
2605 Joppa Road
York, PA 17403
ATTN: Privacy Officer
The Privacy Officer can be
contacted by telephone at 717 747 5777
IX. Effective Date
This
Notice is effective on April 14, 2003.
ACKNOWLEDGEMENT
I, ______________________________ (patient), acknowledge
that I have received a copy of Family Center For Allergy and Asthma Notice
Regarding Privacy of Personal Health Information.
________________ ____________________________
Date (Patient’s
Signature)