|
HIPAA Privacy Notice |
|
NOTICE OF PRIVACY PRACTICES 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. I. Who We Are This
Notice describes the privacy practices of your medical billing company. II. Our Privacy Obligations We
are required by law to maintain the privacy of your health information
("Protected Health Information" or "PHI") and to provide
you with this Notice of our legal duties and privacy practices with respect
to your Protected Health Information. When we use or disclose your Protected
Health Information, we are required to abide by the terms of this Notice (or
other notice in effect at the time of the use or disclosure). III. Permissible Uses and Disclosures Without Your Written
Authorization In
certain situations, which we will describe in Section IV below, we must
obtain your written authorization in order to use and/or disclose your PHI.
However, we do not need any type of authorization from you for the following
uses and disclosures: A. Uses and Disclosures for Medical Billing Operations.
We may use and disclose PHI, but not your
"Highly Confidential Information" (defined in Section IV. C below),
in order to treat you, obtain payment for equipment and services provided to
you and conduct our "healthcare operations" as detailed below: ยท
Payment. We
may use and disclose your PHI to obtain payment for equipment and services
that we provide to you -- for example, disclosures to claim and obtain
payment from your health insurer, HMO, or other company that arranges or pays
the cost of some or all of your healthcare (Your Payor")
to verify that Your Payor will pay for healthcare. B. Disclosure to Relatives, Close Friends and Other
Caregivers. We may use or disclose your PHI to a family member, other
relative, a close personal friend or any other person identified by you when
you are present for, or otherwise available prior to, the disclosure, if we
(1) obtain your agreement; (2) provide you with the opportunity to object to
the disclosure and you do not object; or (3) reasonably infer that you do not
object to the disclosure. If you are not present, or the opportunity to agree
or object to a use or disclosure cannot practicably be provided because of
your incapacity or an emergency circumstance, we may exercise our
professional judgment to determine whether a disclosure is in your best
interests. If we disclose information to a family member, other relative or a
close personal friend, we would disclose only information that we believe is
directly relevant to the person?s
involvement with your healthcare or payment related to your healthcare. We
may also disclose your PHI in order to notify (or assist in notifying) such
persons of your location, general condition or death. C. Public Health Activities. We may
disclose your PHI for the following public health activities: (1) to report
health information to public health authorities for the purpose of preventing
or controlling disease, injury or disability; (2) to report child abuse and
neglect to public health authorities or other government authorities
authorized by law to receive such reports; (3) to report information about
products and services under the jurisdiction of the U. S. Food and Drug Administration;
(4) to alert a person who may have been exposed to a communicable disease or
may otherwise be at risk of contracting or spreading a disease or condition;
and (5) to report information to your employer as required under laws
addressing work- related illnesses and injuries or workplace medical
surveillance. D. Victims of Abuse, Neglect or Domestic Violence. If we
reasonably believe you are a victim of abuse, neglect or domestic violence,
we may disclose your PHI to a governmental authority, including a social
service or protective services agency, authorized by law to receive reports
of such abuse, neglect, or domestic violence. E. Health Oversight Activities. We may
disclose your PHI to a health oversight agency that oversees the healthcare
system and is charged with responsibility for ensuring compliance with the
rules of government health programs such as Medicare or Medicaid. F. Judicial and Administrative Proceedings. We may
disclose your PHI in the course of a judicial or administrative proceeding in
response to a legal order or other lawful process. G. Law Enforcement Officials. We may
disclose your PHI to the police or other law enforcement officials as
required or permitted by law or in compliance with a court order or a grand
jury or administrative subpoena. H. Decedents. We may disclose your PHI
to a coroner or medical examiner as authorized by law. I. Organ and Tissue Procurement. We may
disclose your PHI to organizations that facilitate organ, eye or tissue
procurement, banking or transplantation. J. Research. We may use or disclose
your PHI without your consent or authorization if an Institutional Review
Board or Privacy Board approves a waiver of authorization for disclosure. K. Health or Safety. We may
use or disclose your PHI to prevent or lessen a serious and imminent threat
to a person?s or the public?s health or safety. L. Specialized Government Functions. We may
use and disclose your PHI to units of the government with special functions,
such as the U. S. military or the U. S. Department of State under certain
circumstances. M. Workers' Compensation. We may
disclose your PHI as authorized by and to the extent necessary to comply with
state law relating to workers compensation or other similar programs. N. As Required by Law. We may
use and disclose your PHI when required to do so by any other law not
already referred to in the preceding categories. IV. Uses and Disclosures Requiring Your Written Authorization A. Use or Disclosure with Your Authorization. For any
purpose other than the ones described above in Section III, we only may use
or disclose your PHI when you grant us your written authorization ("Your
Authorization"). For instance, you will need to execute an authorization
before we can send your PHI to your life insurance company or to the attorney
representing the other party in litigation in which you are involved. B. Marketing. We must also obtain your
written authorization ("Your Marketing Authorization") prior to
using your PHI to send you any marketing materials. In addition, we may
communicate with you about products or services relating to your treatment,
case management or care coordination, or alternative treatments, therapies,
providers or care settings without Your Marketing Authorization. C. Uses and Disclosures of Your
Highly Confidential Information. In addition, federal and state law require special privacy protections for certain highly
confidential information about you ("Highly Confidential
Information"). We will comply with such special privacy protections
which may cover the subset of your PHI that: (1) is maintained in
psychotherapy notes; (2) is about mental health and developmental
disabilities services; (3) is about alcohol and drug abuse prevention,
treatment and referral; (4) is about HIV/AIDS testing, diagnosis or
treatment; (5) is about venereal disease(s); (6) is about genetic testing;
(7) is about child abuse and neglect; (8) is about domestic abuse of an adult
with a disability; (9) is about sexual assault; or (10) is about abortion. V. Your Rights Regarding Your Protected Health Information A. For Further Information; Complaints. If you
desire further information about your privacy rights, are concerned that we
have violated your privacy rights or disagree with a decision that we made
about access to your PHI, you may contact our Physician and Patient Relations
Department. You may also file written complaints with the Director, Office
for Civil Rights of the U. S. Department of Health and Human Services. Upon
request, the Physician and Patient Relations Department will provide you with
the correct address for the Director. We will not retaliate against you if
you file a complaint with us or the Director. B. Right to Request Restrictions. You may
request restrictions on our use and disclosure of your PHI (1) for treatment,
payment and healthcare operations; (2) to individuals (such as a family
member, other relative, close personal friend or any other person identified
by you) involved with your care or with payment related to your care; or (3)
to notify or assist in the notification of such individuals regarding your
location and general condition. While we will consider all requests for
restrictions carefully, we are not required to agree to a requested
restriction. If you wish to request restrictions, please submit a written
request to our Physician and Patient Relations Department. A form to request
restrictions is available upon request from the Physician and Patient
Relations Department. C. Right to Receive Confidential Communications. You may
request, and we will accommodate, any reasonable written request for you to
receive your PHI by alternative means of communication or at alternative
locations. D. Right to Revoke Your Authorization. You may
revoke Your Authorization, Your Marketing Authorization or any written
authorization obtained in connection with your Highly Confidential
Information, except to the extent that we have taken action in reliance upon
it, by delivering a written revocation statement to the Physician and Patient
Relations Department identified below. A form of written revocation is
available upon request from the Physician and Patient Relations Department. E. Right to Inspect and Copy Your Health
Information. You may request access to your medical record file and
billing records maintained by us in order to inspect and request copies of
the records. Under limited circumstances, we may deny you access to a portion
of your records. If you desire access to your records, please submit a
written request to the Physician and Patient Relations Department. You may
obtain a record request form from the Physician and Patient Relations
Department and submit the completed form to the Physician and Patient
Relations Department. Requests for a copy of a limited amount of your medical
or billing records (e. g., a prescription) maintained by us on- site may be
made orally to our local facility. We may, however, require that you submit a
written request to the Physician and Patient Relations Department. F. Right to Amend Your Records. You have
the right to request that we amend Protected Health Information
maintained in your medical record file or billing records. If you desire to
amend your records, please send a written request for the amendment,
including the reason for the amendment, to the Physician and Patient
Relations Department. You may obtain a form to request an amendment from the
Physician and Patient Relations Department. We will comply with your request
unless we believe that the information that would be amended is accurate and
complete or other special circumstances apply. G. Right to Receive an Accounting of Disclosures. Upon
request, you may obtain an accounting of certain disclosures of your PHI made
by us during any period of time prior to the date of your request provided
such period does not exceed six years and does not apply to disclosures that
occurred prior to April 14, 2003. H. Right to Receive Paper Copy of This Notice. Upon
request, you may obtain a paper copy of this Notice, even if you have agreed
to receive such notice electronically. VI. Effective Date and Duration of This Notice A. Effective Date. This
Notice is effective as of September 1, 2005. B. Right to Change Terms of This Notice. We
reserve the right to, meaning we may, change the terms of this Notice at any
time. If we change this Notice, we may make the new notice terms effective
for all Protected Health Information that we maintain, including any
information created or received prior to issuing the new notice. If we change
this Notice, we will post the new notice on our Internet site. You also may
obtain any new notice by contacting the Physician Online Inc via the Contact
Us page. VII. Physicians Online Inc. You
may contact the Physicians Online Inc: Physician Online Inc ACKNOWLEDGMENT Please
acknowledge your receipt of this Notice of Privacy Practices by filling in
the requested information below, signing it and returning it to: Physician
Online Inc Printed
Name: __________________________________________________ |