Women’s Health Wise
Notice of Privacy Practices for Protected Health
Information
Effective Date: April 14, 2003
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!
The office is
permitted by federal privacy laws to make uses and disclosures of your
health
information for purposes of treatment, payment, and health care
operations. Protected health
information is the information we create and obtain in providing our
services
to you. Such information may include
documenting your symptoms, examination, and test results, diagnoses,
treatment,
and applying for future care or treatment.
It also includes billing documents for those
services.
Examples of Uses of Your Health
Information for Treatment Purposes are:
·
The waiting area is shared and your name will be
called
when the doctor is ready for your appointment. If you object to this, please
tell us.
·
A nurse
or
physician obtains treatment information about you and records it in a health
record.
·
During
the
course of your treatment, the physician determines he/she will need to
consult
with another specialist in the area.
He/she will share the information with such specialist and obtain
his/her input.
·
The staff may
disclose
medical information about you to doctors not affiliated with Women’s Health
Wise, if that doctor(s) provides on-call coverage for our doctor in order to
insure continuity of care.
·
The
staff
may contact you for appointment reminders, or to inform you of possible
treatment alternatives or health related services that may be of interest to
you.
Example of Use of Your Health
Information
for Payment Purposes:
We submit
requests for payment to your health insurance company. The health insurance company (or other
business associate helping us obtain payment) requests information from us
regarding medical care given. We
will
provide information to them about you and the care
given.
Example of Use of Your Information for
Health Care Operations:
We obtain
services from our insurers or other business associates such as quality
assessment, quality improvement, outcome evaluation, protocol and clinical
guideline development, training programs, credentialing, medical review,
legal
services, and insurance. We will
share
information about you with such insurers or other business associates as
necessary to obtain these services.
Your
Health Information Rights
The health and billing records we
maintain are the physical property of the office. The information in it, however, belongs to you. You have a right to:
·
Request
a
restriction on certain uses and disclosures of your health information by
delivering the request to our office -- we are not required to grant the
request, but we will comply with any request granted;
·
Obtain a
paper copy of the current Notice of Privacy Practices for Protected Health
Information ("Notice") by making a request at our
office;
·
Request
that you be allowed to inspect and copy your health record and billing
record –
you may exercise this right by delivering the request to our
office;
·
Appeal a
denial of access to your protected health information, except in certain
circumstances;
·
Request
that your health care record be amended to correct incomplete or incorrect
information
by delivering a request to our office.
We may deny your request if you ask us to amend information
that:
·
Was not
created by us, unless the person or entity that created the information is
no
longer available to make the amendment;
·
Is not
part
of the health information kept by or for the office;
·
Is not
part
of the information that you would be permitted to inspect and copy;
or,
·
Is
accurate
and complete.
If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records;
·
Request
that communication of your health information be made by alternative means
or
at an alternative location by delivering the request in writing to our
office;
Obtain an
accounting of disclosures of your health information as required to be
maintained by law by delivering a request to our office. An accounting will not include uses and
disclosures of information for treatment, payment, or operations;
disclosures
or uses made to you or made at your request; uses or disclosures made
pursuant
to an authorization signed by you; uses or disclosures made in a facility
directory or to family members or friends relevant to that person's
involvement
in your care or in payment for such care; or, uses or disclosures to notify
family or others responsible for your care of your location, condition, or
your
death.
·
Revoke
authorizations that you made previously to use or disclose information by
delivering a written revocation to our office, except to the extent
information
or action has already been taken.
If you
want
to exercise any of the above rights, please contact the Practice Privacy
Officer at:
630 15th Ave Ste. 200, Longmont CO
80501
(303)
776-5820;
in person or
in
writing, during regular, business hours.
[S]he will inform you of the steps that need to be taken to exercise
your rights.
The office is required
to:
·
Maintain
the privacy of your health information as required by
law;
·
Provide
you
with a notice as to our duties and privacy practices as to the information
we
collect and maintain about you;
·
Abide by
the terms of this Notice;
·
Notify
you
if we cannot accommodate a requested restriction or request;
and,
·
Accommodate
your reasonable requests regarding methods to communicate health information
with you.
We reserve
the
right to amend, change, or eliminate provisions in our privacy practices and
access practices and to enact new provisions regarding the protected health
information we maintain. If our
information practices change, we will amend our Notice. You are entitled to receive a revised
copy
of the Notice by calling and requesting a copy of our "Notice" or
by
visiting our office and picking up a copy.
To Request Information or File a
Complaint
If you have
questions, would like additional information, or want to report a problem
regarding the handling of your information, you may contact the Practice Privacy Officer as discussed
above.
Additionally,
if
you believe your privacy rights have been violated, you may file a written
complaint at our office by delivering the written complaint to the Practice Privacy Officer. You may also file a complaint by mailing
it
or e-mailing it to the Secretary of Health and Human Services, whose street
address and e-mail address is:
Office
for Civil Rights - U.S. Department of Health and Human Services - 200
Independence Avenue S.W. - Room 509F, HHH Building - Washington, D.C. 20201.
·
We
cannot,
and will not, require you to waive the right to file a complaint with the
Secretary of Health and Human Services (HHS) as a condition of receiving
treatment from the office.
·
We
cannot,
and will not, retaliate against you for filing a complaint with the
Secretary
of Health and Human Services.
·
Using
our
best judgment, we may disclose to a family member, other relative, close
personal friend, or any other person you identify, health information
relevant
to that person's involvement in your care or in payment for such care if you
do
not object or in an emergency.
·
Unless
you
object, we may use or disclose your protected health information to notify,
or
assist in notifying, a family member, personal representative, or other
person
responsible for your care, about your location, and about your general
condition, or your death.
·
We may
disclose information to researchers when their research has been approved by
an
institutional review board that has reviewed the research proposal and
established
protocols to ensure the privacy of your protected health
information.
·
We may
use
and disclose your protected health information to assist in disaster relief
efforts.
·
Consistent
with applicable law, we may disclose your protected health information to
organ
procurement organizations or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose of tissue donation and
transplant.
Food and Drug Administration
(FDA)
·
We may
disclose to the FDA your protected health information relating to adverse
events with respect to food, supplements, products and product defects, or
post-marketing surveillance information to enable product recalls, repairs,
or
replacements.
·
If you
are
seeking compensation through Workers Compensation, we may disclose your
protected health information to the extent necessary to comply with laws
relating to Workers Compensation.
·
As
authorized by law, we may disclose your protected health information to
public
health or legal authorities charged with preventing or controlling disease,
injury, or disability; to report reactions to medications or problems with
products; to notify people of recalls; to notify a person who may have been
exposed to a disease or who is at risk for contracting or spreading a
disease
or condition.
·
We may
disclose your protected health information to public authorities as allowed
by
law to report abuse or neglect.
·
We may
release health information about you to your employer if we provide health
care
services to you at the request of your employer, and the health care
services
are provided either to conduct an evaluation relating to medical
surveillance
of the workplace or to evaluate whether you have a work-related illness or
injury. In such circumstances, we
will
give you written notice of such release of information to your
employer. Any other disclosures to your employer
will
be made only if you execute a specific authorization for the release of that
information to your employer.
·
If you
are
an inmate of a correctional institution, we may disclose to the institution
or
its agents the protected health information necessary for your health and
the
health and safety of other individuals.
·
We may
disclose your protected health information for law enforcement purposes as
required by law, such as when required by a court order, or in cases
involving
felony prosecution, or to the extent an individual is in the custody of law
enforcement.
·
Federal
law
allows us to release your protected health information to appropriate health
oversight agencies or for health oversight activities.
·
We may
disclose your protected health information in the course of any judicial or
administrative proceeding as allowed or required by law, with your
authorization, or as directed by a proper court order.
·
To avert
a
serious threat to health or safety, we may disclose your protected health
information consistent with applicable law to prevent or lessen a serious,
imminent threat to the health or safety of a person or the
public.
·
We may
disclose your protected health information for specialized government
functions
as authorized by law such as to Armed Forces personnel, for national
security
purposes, or to public assistance program personnel.
·
We may
release health information to a coroner or medical examiner. This may be necessary, for example, to
identify a deceased person or determine the cause of death. We may also release health information
about
patients to funeral directors as necessary for them to carry out their
duties.
·
Other
uses
and disclosures, besides those identified in this Notice, will be made only
as
otherwise required by law or with your written authorization and you may
revoke
the authorization as previously provided in this Notice under "Your
Health
Information Rights."
·
If we maintain a website that provides information
about our entity, this Notice will be on the website.
By signing below,
I
acknowledge that I have read and received a copy of this
notice.
Signature:__________________________________
Printed
name:_______________________________
Date:_________________________