NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice tells you about the ways in which LifeSmiles of New Hope, P.C. (referred to as “We” or “the Plan”) may collect, use and disclose your protected health information and your rights concerning your protected health information. “Protected health information” is information about you, including demographic information, that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care. We are required by federal and state laws to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information. We must follow the terms of this Notice while it is in effect. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards
HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
We may use and disclose your protected health information for different purposes. The examples below are provided to illustrate the types of uses and disclosures we may make without your authorization for payment, health care operations and treatment.
Payment. We use and disclose your protected health information in order to pay for your covered health expenses. For example, we may use your protected health information to process claims or be reimbursed by another insurer that may be responsible for payment.
Health Care Operations. We use and disclose your protected health information in order to perform our plan activities, such as quality assessment activities or administrative activities, including data management or customer service. In some cases, we may use or disclose the information about alternative treatments.
Treatment. We may use and disclose your protected health information to assist your health care providers (doctors, dentists, pharmacies, hospitals, and others) in your diagnosis and treatment. For example, we may disclose your protected health information to providers to provide information about alternative treatments.
Plan Sponsor. If you are enrolled through a group health plan, we may provide summaries of claims and expenses for enrollees in a group health plan to the plan sponsor, who is usually the employer.
Enrolled Dependents and Family Members. We will mail explanation of benefits forms and other mailings containing protected health information to the address we have on record for the subscriber of the health plan.
As Required by Law. We must disclose protected health information about you when required to do so
Public Health Activities. We may disclose protected health information to public health agencies for reasons such as preventing or controlled disease, injury or disability
Victims of Abuse, Neglect or Domestic Violence. We may disclose protected health information to government agencies (e.g., state insurance departments) for activities authorized by law.
Judicial and Administrative Proceedings. We may disclose protected health information in response to a court or administrative order. We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request or other lawful process.
Special Government Functions. We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities programs.
Workers’ Compensation. We may disclose protected health information to the extent necessary to comply with state law for workers’ compensation programs.
OTHER USES OR DISCLOSURES WITH AN AUTHORIZATION
Other uses or disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization at any time in writing, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information to contest a claim or coverage under the Plan.
YOU’RE RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Right to Access Your Protected Health Information: You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Usually the records include enrollment, billing, claims payment and case or medical management records. Your request to review and/or obtain a copy of your protected health information records must be made in writing. We may charge a fee for the costs of producing, copying and mailing your requested information, but we will tell you the cost in advance.
Right to an Accounting of Disclosure by the Plan: You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security proposes. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper or electronically). The first accounting that you request within a 12-month period will be at no charge. For additional lists within the same time period, we may charge for providing the accounting, but we will tell you the cost in advance.
Right to Request Restrictions on the Use and Disclosure of Your Protected Health Information: You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment or health care options. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply.
Right to Receive Confidential Communications. You have the right to request that we use a certain method to communicate with you about the Plan or that we send Plan information to a certain location if the communication could endanger you. Your request to receive confidential communication from us could endanger you. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice: You have the right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy.
Contact Information for Exercising Your Rights: You may exercise any of the rights described above by
contacting our privacy office. See the end of this Notice for the contact information.
Health Information Security: LifeSmiles of New Hope, P.C. requires its employees to follow the LifeSmiles of New Hope, P.C. security policies and procedures that limit access to health information about members to those employees who need it to perform their job responsibilities. In addition, LifeSmiles of New Hope, P.C. maintains physical, administrative and technical security measures to safeguard your protected health information.
Changes to This Notice: We reserve the right to change the terms of this Notice at any time, effective for protected health information that we already have about you as well as any information that we receive in the future. We will provide you with a copy of the new Notice whenever we make a material change to the privacy practices described in this Notice. We also post a copy of our current Notice on our website at LifeSmilesof newhope.com. If at any time we make a material change to this Notice, we will promptly revise and issue the new Notice with the new effective date.
Complaints: If you believe that your privacy rights have been violated, you may file a complaint with us and/or with the Secretary of the Department of Health and Human Services. All complaints to the Plan must be made in writing and sent to the privacy office listed at the end of this Notice. We support your right to protect the privacy of your protected health information. We will not retaliate against you or penalize you for filing a complaint.
LifeSmiles of New Hope, P.C.
Privacy Officer : Dr. Dharmesh Parbhoo
Address: 49 Hosiery Mill Road, Suite 125
Dallas, Georgia 30157
Phone : (770) 445-1314
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan, and direct my treatment and follow-up among the multiple healthcare Provider’s who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician Certification’s.