Notice of Privacy Practices

Please correct the errors described below.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION* ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

*Protected Health Information (PHI)

PLEASE REVIEW IT CAREFULLY

Notice Effective Date: June 1, 2019 (Version 1)

Privacy

Dr. Otha Myles & Associates, LLC (DMA) is required by state and federal law to maintain the privacy of your protected health information (PHI). PHI includes any identifiable information about your physical or mental health, the health care you receive, and the payment for your health care.

DMA is required by law to provide you with this notice to tell you how it may use and disclose your PHI and to inform you of your privacy rights. DMA must follow the privacy practices as set forth in its most current Notice of Privacy Practices.

This notice refers only to the use/disclosure of PHI. It does not change existing law, regulations and policies regarding informed consent for treatment.

Changes to this Notice

DMA may change its privacy practices and the terms of this notice at any time. Changes will apply to PHI that DMA already has as well as PHI that DMA receives in the future. The most current privacy notice will be posted in DMA facilities and programs, and on the DMA website (summershealthcare.com) and will be available on request. Every privacy notice will be dated.

How Does DMA Use and Disclose PHI?

DMA may use/disclose your PHI for treatment, payment and health care operations without your authorization. Otherwise, your written authorization is needed unless an exception listed in this notice applies.

Uses/Disclosures Relating to Treatment, Payment and Health Care Operations

The following examples describe some, but not all, of the uses/disclosures that are made for treatment, payment and health care operations.

For treatment - Consistent with its regulations and policies, DMA may use/disclose PHI to doctors, nurses, service providers and other personnel (e.g., interpreters), who are involved in delivering your health care and related services. Your PHI will be used to help make a determination on your application for DMA services, to assist in developing your treatment and/or service plan and to conduct periodic reviews and assessments. PHI may be shared with other health care professionals and providers to obtain prescriptions, lab work, consultations and other items needed for your care. PHI will be shared with DMA service providers for the purposes of referring you for DMA services and then for coordinating and providing the DMA services you receive.

To obtain payment - Consistent with the restrictions set forth in its regulations and policies, DMA may use/disclose your PHI to bill and collect payment for your health care services DMA may release portions of your PHI to the Medicaid or Medicare program or a third party payor to determine if they will make payment, to get prior approval and to support any claim or bill.

For health care operations - DMA may use/disclose PHI to support activities such as program planning, management and administrative activities, quality assurance, receiving and responding to complaints, compliance programs (e.g., Medicare), audits, training and credentialing of health care professionals, and certification and accreditation. Dr. Myles & Associates, LLC will not disclose any information for advertising/ marketing without the consent of the patient.

Appointment Reminders

DMA may use PHI to remind you of an appointment or to provide you with information about treatment alternatives or other health related benefits and services that may be of interest to you.

Uses/Disclosures Requiring Authorization

DMA is required to have a written authorization from you or your personal representative with the legal authority to make health care decisions on your behalf for uses/disclosures beyond treatment, payment and health care operations unless an exception listed below applies. You may cancel an authorization at any time, if you do so in writing. A cancellation will stop future uses/disclosures except to the extent DMA has already acted based upon your authorization.

Exceptions

• For guardianship or commitment proceedings when DMA is a party

• For judicial proceedings if certain criteria are met

• For protection of victims of abuse or neglect

• For research purposes, following strict internal review

• If you agree, verbally or otherwise, DMA may disclose a limited amount of PHI for the following purposes:

  • Clergy – Your religious affiliation may be shared with clergy
  • To Family and Friends – DMA may share information directly related to their involvement in your care, or payment for your care

• To correctional institutions, if you are an inmate

• For federal and state oversight activities such as fraud investigations, usual incident reporting, and protection and advocacy activities

• If required by law, or for law enforcement or national security

• To avoid a serious and imminent threat to public health or safety

• For public health activities such as tracking diseases and reporting vital statistics

• Upon death, to funeral directors and certain organ procurement organizations

Your Rights

You, or a personal representative with legal authority to make health care decisions on your behalf, have the right to:

• Request that DMA use a specific address or telephone number to contact you. DMA is not required to comply with your request.

• Obtain, upon request, a paper copy of this notice or any revision of this notice, even if you agreed to receive it electronically.

• *Inspect and copy PHI that may be used to make decisions about your care. Access to your records may be restricted in limited circumstances. If you are denied access, in certain circumstances, you may request that the denial be reviewed. Fees may be charged for copying and mailing.

• *Request additions or corrections to your PHI. DMA is not required to comply with a request. If it does not comply with your request, you have certain rights.

• *Receive a list of individuals who received your PHI from DMA (excluding disclosures that you authorized or approved, disclosures made for treatment, payment and healthcare operations and some required disclosures).

• *Ask that DMA restrict how it uses or discloses your PHI. DMA is not required to agree to a restriction.

* These requests must be made in writing

To Contact DMA or to File a Complaint

If you want to obtain further information about DMA’s privacy practices, or if you want to exercise your rights, or you feel your privacy rights have been violated, or you want to file a complaint, you may contact: DMA Privacy Officer, TBD Phone: (314) 833-4001, Fax: 228-0048 Email: TBD. A complaint must be made in writing.

No one may retaliate against you for filing a complaint or for exercising your rights as described in this notice.

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.

Your message will be encrypted.