As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability Act of 1996 (HIPAA)
This Notice describes how medical information about you (as a patient of this practice) may be used and disclosed, and how you can get access to this information. Please review this notice carefully.
A. Our Commitment to Your Privacy
Our practice is dedicated to maintaining the privacy of your protected health information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:
- How we may use and disclose your PHI
- Your privacy rights in regard to your PHI
- Our obligations concerning the use and disclosure of your PHI
- How you can lodge a complaint about how we handle your PHI without your approval for certain matters
The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our Notice of Privacy Practices in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
B. If you have questions about this Notice, please contact:
Caring Hands Children’s Clinic, LLC
C. We May Use and Disclose your protected health information (PHI) in the following ways:
Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice-including but not limited to our doctors and nurses-may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally we may disclose your PHI to others who may assist in your care, such as your spouse, children, or parents.
Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items.
Health Care Operations:
Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us or to conduct cost-management and business planning activities for our practice.
Our practice may use and disclose your PHI to inform you or potential treatment options or alternatives.
Release of Information to Family/Friends:
Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a guardian may ask that a neighbor take their parent or child to the physician’s office for treatment. The neighbor may have access to this patient’s medical information.
Disclosures Required by Law
Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.
D. Use and disclosure of your PHI in certain special circumstances without your approval:
The following categories describe unique scenarios in which we may use or disclose your PHI without your consent or authorization.
Public Health Risks:
Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purposes of:
- Maintaining vital records, such as births and deaths
- Reporting child abuse or neglect
- Preventing or controlling disease, injury or disability
- Notifying a person regarding a potential risk for spreading or contracting a disease or condition
- Reporting reactions to drugs or problems with products or devices
- Notifying individuals if a product or device they may be using has been recalled
- Notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
- Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance
Health Oversight Activities:
Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
Lawsuits and Similar Proceedings:
Our practice may disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
We may release PHI if asked to do so by a law enforcement official:
- Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
- Concerning a death we believe has a resulted from criminal conduct
- Regarding criminal conduct at our offices
- In response to a warrant, summons, court order, subpoena or similar legal process
- To identify/locate a suspect, material witness, fugitive or missing person
- In an emergency, to report a crime (including the location or victims of the crime, or the description, identity or location of the perpetrator)
Serious Threats to Health or Safety:
Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
Our practice may use and disclose your PHI to federal officials for intelligence and national security activities authorized by the law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
E. Your Rights Regarding Your PHI
You have the following rights regarding the PHI that we maintain:
You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make written request to Keith Taylor, Office Manager, PO Box 1400, Monticello, MS 39654 specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to the request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Keith Taylor, Office Manager, PO Box 1400, Monticello, MS 39654. Your request must describe in a clear and concise fashion:
- The information you wish restricted;
- Whether you are requesting to limit our practice’s use, disclosure or both; and
- To whom you want the limits to apply.
Inspection and Copies:
You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Keith Taylor, Office Manager, PO Box 1400, Monticello, MS 39654 in order to inspect and/or obtain a copy or your PHI. Our practice may charge a fee for the costs of copying associated with your request.
You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Keith Taylor, Office Manager, PO Box 1400, Monticello, MS 39654. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
Accounting and Disclosures:
All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for non-treatment or operations purposes. Use of your PHI as part of the routine patient care in our practice is not required to bed documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Keith Taylor, Office Manager, PO Box 1400, Monticello, MS 39654. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
Right to a Paper Copy of This Notice:
You are entitled to receive a paper copy of our notice of privacy practices. You will be offered a copy on your first visit to the practice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice contact Keith Taylor, Office Manager, PO Box 1400, Monticello, MS 39654.
Right to Provide an Authorization for Other Uses and Disclosures:
Our practice will obtain your written authorization for uses and disclosures that are not covered by this notice or permitted by applicable law, such as for research or marketing. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care.
Again, if you have any questions regarding this notice or our health information privacy policies, please contact Keith Taylor, Office Manager, PO Box 1400, Monticello, MS 39654.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.