|
NOTICE OF PRIVACY PRACTICES
Michael O. LaGrone, M.D.
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 follow the privacy practices that are described in this Notice
while it is in effect. This Notice takes effect June 18, 2003, and will
remain in effect until we replace it. It replaces Notice dated March 18,
2003.
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 received 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 in 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 health information to a physician or healthcare provider providing
treatment to you.
Payment: We may use or 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 include quality assessment and
improvement activities, reviewing the competence or qualifications of
healthcare professionals, evaluating practitioner and provider
performance, conducting training programs, accreditation, certification,
licensing or credentialing activities.
Your Authorization: In addition to
our use of your health information for treatment, payment or healthcare
operations, you may give us written authorization to use your health
information to disclose it to anyone for any purpose. If you give us
authorization, you may revoke it in writing at any time. Your revocation
will not affect any use or disclosures permitted by your authorization
while it was in effect. Unless you give us written authorization, we
cannot use or disclose your health information for any reason except
those described in this Notice.
To Your Family and Friends: We
must disclose your health information to you, as described in the
Patient Rights section of this Notice. We may disclose your health
information to a family member, friend or other person to the extent
necessary to help 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 or disclose health information to notify, or assist in the
notification of (including identifying or locating) a family member,
your personal representative or another person responsible for your
care, or 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 the opportunity to object to such uses or
disclosures. In the event of your incapacity or emergency circumstances,
we will disclose health information based on a determination 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 judgment 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 that 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 avert a serious threat to
your health or safety or the health or safety of others.
National Security: We may disclose
to military authorities the health information of Armed Forces personnel
under certain circumstances. We may disclose to 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 of inmate or patient under certain circumstances.
Appointment Reminders: We may use
or disclose your health information to provide you with appointment
reminders in the manner you have chosen ( home telephone, work
telephone, in writing, etc.)
PATIENT RIGHTS
Access: You have the right to look
at or get photocopies of your health information, with limited
exceptions. You must make a request in writing to obtain access to your
health information. You may obtain a 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 copies and staff time.
You may also request access by sending us a letter to the address at the
end of this Notice. If you request copies, we will charge you $25.00 for
the first twenty pages and $.50 per page for each page up to twenty and
each page that exceeds twenty. This fee is for staff time to locate and
copy your health information. In addition we will charge you for postage
if you want the copies mailed to you.
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 six 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. That fee will be $15.00.
Restriction: You have the right to
request that we place additional restrictions on our use or disclosure
of your health information. We are NOT required to agree to these
additional restrictions, but if we do, we will abide by your agreement
(except in an emergency).
Alternative Communication: You
have the right to request that we communicate with you about your health
information by alternative means. You must make this request in writing
specifying the alternative means or location, and provide satisfactory
explanation how payments will be handled under the alternative 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.
QUESTIONS AND COMPLAINTS
If you want more information about our
privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have
violated your privacy rights, or you disagree with a decision we made
about access to your health information or in response to a request you
made to amend or restrict the use or disclosure of your health
information or to have us communicate with you by alternative means or
at alternative locations, you may complain to us using the contact
information listed at the end of this Notice. You also may submit a
written complaint to the U.S. Department of Health and Human Services.
We will provide you with the address to file your complaint with the
U.S. Department of Health and Human Services upon request.
We support your right to the privacy of
your health information. We will not retaliate in any way if you choose
to file a complaint with us or with the U.S. Department of Health and
Human Services.
|
