(NAME OF PROVIDER)
(Address, City, State, Zip and
Phone of provider)
NOTICE OF PRIVACY
PRACTICES
(model for solo and
small group practices)
-------------------------------------------------------------------------------------
The
Effective Date of This Notice is ________________________________.
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.
This page describes
the type of information we gather about you, with whom that information may be
shared and the safeguards we have in place to protect it. You have the right to the confidentiality of
your medical information and the right to approve or refuse
the release of specific information except when the release is required by law,
or permitted by law without your authorization.
If the practices described in this notice meet your expectations, there is
nothing you need to do. If you prefer additional limitations on the use of your medical information, you may
request them by following the procedure below.
If you have any questions about this notice, please contact our Privacy
Officer at the address above.
This notice describes the Provider's
practices regarding the use of your medical information and that of:
·
Any health care professional employed by
the (Provider) who is authorized to enter information into your medical record.
·
Any member of a volunteer group we allow
to help you.
·
All employees, staff and other personnel
who may need access to your information.
·
If
we have, or in the future will have, multiple sites or locations, all of them
will adhere to the provisions in this notice.
Multiple sites and locations may share medical information with each other
for treatment, payment or health care operations purposes as described in this notice.
Our
Pledge Regarding Medical Information
We understand that medical information about you
and your health is personal. Protecting
medical information about
you is important. We create a record of
the care and services you receive. We
need this record to provide you with quality care and to comply with certain
legal requirements. This notice applies to all of the records of your care generated
by (the Provider)'s employees, whether made by health care professionals or
other personnel.
This notice will tell you about the ways in which we may use and disclose
medical information about you. We also describe your
rights and certain obligations we have regarding the use and disclosure of personal medical information.
We are required by
law to:
·
Keep confidential any medical information that concerns your condition or treatment, how your
care is paid for and demographic information, if such information can be used
to identify you;
·
give you this notice of our policies,
procedures and information privacy practices with respect
to medical information about you; and
• follow the terms of the notice that is currently
in effect.
How We May Use and Disclose Medical
Information About You
The following
categories describe different ways that we may use and disclose medical information. For each category of uses or disclosures
we will try to give some examples. Not
every use or disclosure in a category will be listed.
For Treatment. We may use medical information about
you to provide you with medical treatment or services. We may disclose medical
information about you to doctors, nurses, technicians, training doctors, or other health care professionals who are involved
in taking care of you. For example, a
doctor treating you for a broken leg may need to know if
you have diabetes because diabetes may slow the healing process. Different health care professionals also may share medical information about
you in order to coordinate the different things you need,
such as prescriptions, lab work and x-rays.
For Payment. We may use and disclose medical
information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an
insurance company or a third party. For example, your insurance may need to know about surgery you received so they
will pay us or reimburse you for the surgery. W e may also use and
disclose medical information about you to obtain prior approval or to determine whether your insurance will cover the
treatment, or to undertake other tasks related to seeking payment for services provided. We may also disclose medical information to
another health care provider who is or has been
involved in your treatment, so that that provider
may seek payment for services rendered.
For Health Care Operations Purposes. We may use and disclose medical information
about you for health
care operations purposes. This is necessary to make sure that all of our
patients receive quality care. For
example, we may use medical information to
review our treatment and services and to evaluate the performance of our
staff in caring for you, or to otherwise
manage and operate more effectively. We
may also disclose information to
doctors, nurses, technicians, training doctors, medical students, and other
hospital personnel for review and
learning purposes. We may
remove information that identifies you from this set of medical information so
others may use it to study health care and health care delivery without
learning who the specific patients are.
Appointment Reminders. We may use and disclose medical information to
contact you as a reminder that you have an
appointment for treatment or medical care.
Treatment Alternatives. We may use and disclose medical information to
tell you about or recommend possible treatment options or alternatives that
may be of interest to you.
Health-Related Benefits and Services. We may use and disclose medical information to
tell you about health related benefits or services that may be
of interest to you.
Individuals Involved in Your Care
or Payment for Your Care.
We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. If you are
in the hospital, we may also tell your family or friends your condition and
that you are in a hospital. In addition, we may disclose medical information about you to an entity
assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Research. Under certain circumstances, we
may use and disclose medical information about you for research purposes. For example, a research
project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same
condition. All research projects, however, are subject to a
special approval process. This process
evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for
privacy of their medical information.
Before we use or disclose medical information
for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about
you to people preparing to conduct a research project, for example, to help
them look for patients with specific medical needs, so long as the medical
information they review does not leave the facility conducting the research.
As Required By Law. We will disclose medical information about you when required to do so by
federal, state or local law.
To Avert a
Serious Threat to Health or Safety. We may use and disclose medical information
about you when necessary to prevent a serious threat to
your health and safety or the health and safety of the public or another person. Any disclosure, however,
would only be to someone able to help prevent the threat.
Fundraising
Activities. We may use medical
information about you in an effort to raise money for a purpose of potential
benefit to you. For example, if you have
a particular medical problem and an entity is conducting fundraising for
research in that area of medical science, we may write you for solicitation of
funds for that entity. We expect this to
occur very rarely. If you do not want us
to contact you for fundraising efforts, you must notify our Privacy Officer in writing at the address below.
Where
Special Situations Requiring Release of
Information
Organ and Tissue Donation. If you are an organ donor, we may release
medical information to organizations that handle organ
procurement or organ, eye or tissue transplantation or to an organ donation
bank, as necessary to facilitate organ or tissue donation and
transplantation.
Military and Veterans.
If you are a member of the armed forces, we may release medical
information about you as required by military command authorities.
Workers' Compensation. We may release medical information about you
for workers' compensation or similar programs. These programs provide benefits for
work-related injuries or illness.
Public Health
Risks. We may disclose medical
information about you for public health activities. These activities generally include the following:
·
to prevent or control disease, injury or
disability;
·
to report births and deaths;
·
to report child abuse or neglect;
·
to report reactions to medications or
problems with products;
·
to notify people of recalls of products
they may be using;
·
to notify a person who may have been
exposed to a disease or may be at risk for contracting or spreading a disease or condition;
·
to notify the appropriate government
authority if we believe a patient has been the victim of abuse, neglect or domestic violence.
Health Oversight Activities. We may disclose medical information to a
health oversight agency for activities authorized by
law. These oversight activities include,
for example, audits, investigations, inspections, and licensure. These activities
are necessary for the government to monitor the overall health care system, the
conduct of government programs, and compliance with
civil rights laws.
Lawsuits and Disputes. We may disclose medical
information about you in response to a subpoena, discovery request, or other lawful order from a court.
Law Enforcement. We may release medical information if asked to do so by a
law enforcement official as part of law enforcement activities; in
investigations of criminal conduct or of victims of crime; in response to court
orders; in emergency circumstances; or when
required to do so by law.
Coroners, Medical Examiners and
Funeral Directors. We may release medical 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 medical information about patients of the hospital to funeral directors
as necessary to carry out their duties.
Protective Services for the
President, National Security and Intelligence Activities. We may release medical information
about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of
state or conduct special investigations, or for intelligence, counterintelligence, and other national security activities authorized by
law.
Inmates and in the Custody of
Law Enforcement.
If you are an inmate of a correctional institution or under the custody
of a law enforcement official, we may release medical
information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care;
(2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the
correctional institution.
Your
Rights Regarding Medical Information About You
You have the following rights regarding
medical information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and
copy medical information that may be used to make decisions about your care. This
includes medical and billing records, but does not include
psychotherapy notes.
To inspect and copy medical information that may be used to
make decisions about you, you must submit your request in
writing to our Privacy Officer at the address below. If you request a copy of the information, we may charge a fee for the
costs of copying, or other unusual supplies associated with your request.
We may deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to medical information,
you may request that the denial be reviewed.
Another licensed health care professional chosen by (the Provider) will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend. If you feel that medical
information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment
for as long as the information is kept.
To request an amendment, your request must be made in writing and submitted
to our Privacy Officer. In addition, you
must provide a reason that supports your request.
We may deny your
request for an amendment if it is not in writing or does not include a reason to support the request. In addition, 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 medical information kept
by the Provider;
· Is not
part of the information which you would be permitted to inspect and copy; or
·
Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an
"accounting of disclosures." This is a list of the
disclosures we made of medical information about you. This accounting will not include many routine
disclosures including those made to you or pursuant to your
authorization, those made for treatment, payment and operations purposes as discussed above, those made to the facility
directory as discussed above, those made for national security and intelligence
purposes, those made to correctional institutions, and those made to law
enforcement in compliance with law.
To request this list
or accounting of disclosures, you must submit your request in writing to our
Privacy Officer. Your request must state a time period that may not be longer than six years and may not include dates before
Right
to Request Restrictions. You have the
right to request a restriction or limitation on the medical information we use or disclose about you for treatment,
payment or health care operations. You also have the right to request a limit on the medical information we disclose about
you to someone who is involved in your care or the payment for your care, like a family member or friend.
We are not required to agree to your request. If we do agree, we will comply with your
request unless the information is needed to provide you
emergency treatment.
To request restrictions, you must make your request in
writing to our Privacy Officer at the address below. In your request, you must
tell us (1) what information you want to limit; (2) whether you want to limit
our use, disclosure or both; and (3) to whom you want the limits to apply.
Right to
Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact
you at work or by mail.
To request
confidential communications, you must make your request in writing to our
Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable
requests. Your request must specify how or where you wish to be contacted.
If complying with your request entails additional expense over our usual
means of communication, we may ask that you reimburse us for
those expenses.
Right to a Paper Copy of This Notice.
You have the right to a paper copy of this notice at any time. Even if you have agreed to receive this notice
electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, please request one from our Privacy
Officer.
Changes To This Notice
We reserve the right to change this notice. We reserve the right to make the
revised or changed notice effective for medical information we already have
about you as well as any information we receive in the future. We will always post a copy of the current
notice in the following location: _____________________ [describe
generally, .i.e. "near main
patient entrances".] The notice will contain, on the first page,
the effective date.
Complaints
If you
believe your privacy rights have been violated, you may file a complaint with us
or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer at the address and phone number
below. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Other
Uses of Medical Information
Other uses and disclosures of medical information not
covered by this notice or the laws that apply to us will be made only with your written authorization.
If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing,
at any time. If you revoke your
permission, we will thereafter no longer use or
disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already
made under your authorization. We are required to retain our records of the care that we
provided to you for six years.
Privacy
Officer
The Provider's Privacy Officer is:
________________________________________________ (Name, Mailing Address, Telephone, Fax, e-mail, other means of correspondence)
Acknowledgement
I hereby acknowledge that I have been presented this Notice of Privacy Practices.
Signature:____________________________________ Date: ________________________
Print Name:__________________________________
Acknowledgement Refused
On this date, the
undersigned patient refused or failed to acknowledge receipt of this Notice of
Privacy Practices.
Date:___________________________________
Name of
Patient:_________________________________________________
Reason for
refusal/failure:_____________________________________________
Signature of Provider Employee:
_______________________________________
(File
Signed Copy with Patient's Record)