April 14, 2003
As Required by the Privacy
Regulations Promulgated Pursuant to the Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
THIS NOTICE
DESCRIBES HOW HEALTH INFORMATION ABOUT YOU
MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO YOUR
IDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW
THIS NOTICE CAREFULLY.
A.
OUR COMMITMENT
TO YOUR PRIVACY
Our organization is
dedicated to maintaining the privacy of your identifiable health
information. 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 maintain the confidentiality of health information that identifies
you. We also are required by law to
provide you with this notice of our legal duties and privacy practices
concerning your identifiable health information. By law, we must follow the terms of the notice of privacy
practices that we have in effect at the time.
To summarize, this
notice provides you with the following important information:
·
How we may use and disclose your
identifiable health information
·
Your privacy rights in your
identifiable health information
·
Our obligations concerning the use and
disclosure of your identifiable health information.
The terms of this notice apply to all records containing
your identifiable health information that are created or retained by our
practice. We reserve the right to
revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for
all of your records our practice has created or maintained in the past, and for
any of your records we may create or maintain in the future. Our organization will post a copy of our
most current notice in our offices in a prominent location, and you may request
a copy of our most current notice during any office visit.
B.
IF YOU HAVE
QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Susan Schnack
at our Cape Coral, Florida business office; telephone 239-772-5155.
C.
WE MAY USE AND
DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS
The following
categories describe the different ways in which we may use and disclose your
identifiable health information:
1.
Treatment. Our organization may use or disclose your
identifiable health information in order to treat you or to assist others or to
assist others in your treatment.
Additionally, we may disclose your identifiable health information to
others who may assist in your care, such as your physician, therapists, spouse,
children, or parents.
2.
Payment. Our organization may use and disclose your
identifiable health information 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 identifiable health information to obtain
payment from third parties who may be responsible for such costs, such as
family members. Also we may use your
identifiable health information to bill you directly for services and items.
3.
Health Care
Operations. Our organization may use and disclose your
identifiable health information to operate our business. As examples of the ways in which we may use
and disclose your information for our operations, our organization may use your
health information to evaluate the quality of care you received from us or to
conduct cost-management and business planning activities for our practice.
4.
Appointment
Reminders. Our organization may use and disclose your
identifiable health information to contact you and remind you of visits /
deliveries / returns.
5.
Health-Related
Benefits and Services. Our organization
may use and disclose your identifiable health information to inform you of
health-related benefits or services that may be of interest to you.
6.
Release of
Information to Family / Friends.
Our organization may release your identifiable health information to a
friend or family member who is helping you pay for your health care or who
assists in taking care of you.
7.
Disclosures
Required By Law. Our organization
will use and disclose your identifiable health information when we are required
to do so by federal, state, or local law.
D.
USE AND
DISCLOSURE OF YOUR HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES
The following
categories describe unique scenarios in which we may use or disclose your
identifiable health information:
1.
Public Health
Risks. Our organization may disclose your
identifiable health information to public health authorities who are authorized
by law to collect information for the purpose 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 potential exposure to a
communicable disease
·
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 agency(ies) and authority(ies)
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.
2.
Health
Oversight Activities. Our organization
may disclose your identifiable health information 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.
3.
Lawsuits and
Similar Proceedings. Our organization
may disclose your identifiable health information in response to a court or
administrative order if you are involved in a lawsuit or similar
proceeding. We also may disclose your
identifiable health information 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.
4.
Law
Enforcement. We may release
identifiable health information 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 might have 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 victim(s) of the crime, or the description, identity or location of the
perpetrator)
5.
Serious
Threats to Health or Safety.
Our organization may use and disclose your identifiable health
information 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.
6.
Military. Our organization may disclose your
identifiable health information if you are a member of U.S. or foreign military
forces (including veterans) and if required by the appropriate military command
authorities.
7.
National
Security. Our organization may disclose your
identifiable health information to federal officials for intelligence and
national security activities authorized by law. We also may disclose your identifiable health information to
federal officials in order to protect the President, other officials or foreign
heads of state, or to conduct investigations.
8.
Inmates. Our organization may disclose your
identifiable health information to correctional or law enforcement officials if
you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be
necessary: (a) for the institution to provide health care services to you; (b)
for the safety and security of the institution; and/or (c) to protect your
health and safety or the health and safety of other individuals.
9.
Workers'
Compensation. Our organization
may release your identifiable health information for workers' compensation and
similar programs.
E.
YOUR RIGHTS
REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION
You have the
following rights regarding the identifiable health information that we maintain
about you:
1.
Confidential
Communications. You have the right
to request that our organization 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 a written request
to Susan Schnack at our Cape Coral, Florida business office; telephone
239-772-5155 specifying the requested method of contact or the location where
you wish to be contacted. Our
organization will accommodate reasonable
requests. You do not need to give a
reason for your request.
2.
Requesting
Restrictions. You have the right
to request a restriction in our use or disclosure of your identifiable health
information for treatment, payment, or health care operations. Additionally, you have the right to request
that we limit our disclosure of your identifiable health information to
individuals involved in your care or the payment for your care, such as family
members and friends. We are not required to agree to your
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 identifiable health information.
You must make your request in writing to Susan Schnack at our Cape Coral,
Florida business office; telephone 239-772-5155. Your request must describe in a clear and concise fashion: (a)
the information you wish restricted; (b) whether you are requesting to limit
our practice's use, disclosure, or both; and (c) to whom you want the limits to
apply.
3.
Inspection and
Copies. You have the right to inspect and obtain a
copy of the identifiable health information 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 Susan Schnack at our Cape Coral, Florida
business office; telephone 239-772-5155 in order to inspect and/or obtain a
copy of your identifiable health information.
Our organization may charge a fee for the costs of copying, mailing,
labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in
certain limited circumstances; however, you may request a review of our
denial. Reviews will be conducted by
another licensed health care professional chosen by us.
4.
Amendment. 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
organization. To request an amendment,
your request must be in writing and submitted to Susan Schnack at our Cape
Coral, Florida business office; telephone 239-772-5155. You must provide us with a reason that
supports you request for amendment. Our
organization 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 (a) accurate and complete; (b) not part of the identifiable health
information kept by or for the organization; (c) not part of the identifiable
health information which you would be permitted to inspect and copy; or (d) not
created by our organization, unless the individual or entity that created the
information is not available to amend the information.
5.
Accounting of
Disclosures. All of our patients
have the right to request an "accounting of disclosures." An "accounting of disclosures" is
a list of certain disclosures our organization has made of your identifiable
health information. In order to obtain
an accounting of disclosures, you must submit your request in writing to Susan
Schnack at our Cape Coral, Florida business office; telephone
239-772-5155. All requests for an
"accounting of disclosures" must state a time period which may not be
longer than six years and may not include dates before April 14, 2003. Our organization will notify you of the
costs involved with requests for an "accounting of disclosures" list. You may withdraw your request before you
incur any costs.
6.
Right to a
Paper Copy of This Notice. You are entitled to
receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this
notice at any time. To obtain a paper
copy of this notice, contact Susan Schnack at our Cape Coral, Florida business
office; telephone 239-772-5155.
7.
Right to File
a Complaint. If you believe your
privacy rights have been violated, you may file a complaint with our
organization or with the Secretary of the Department of Health and Human
Services. To file a complaint with our
organization, contact Susan Schnack at our Cape Coral, Florida business office;
telephone 239-772-5155. All complaints
must be submitted in writing. You will not be penalized for filing a
complaint.
8.
Right to
Provide an Authorization for Other Uses and Disclosures. Our organization will obtain your written
authorization for uses and disclosures that are not identified by this notice
or permitted by applicable law. Any
authorization you provide to us regarding the use and disclosure of your
identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will
no longer use or disclose your identifiable health information for the reasons
described in the authorization. Please
note, we are required to retain records of your care.