Hilliard Family Medicine, Inc.
Notice of Privacy Practices
(NOTE: Below is the Notice of Privacy Practices for Hilliard Family Medicine, Inc. Effective 4/14/03, federal law requires that ALL of our patients receive a copy of this Notice, and have a signed consent form on file with our office, indicating your acceptance of the terms of the privacy statement. If you would like to obtain a consent form to print, sign, and deliver to our office, please click here.)
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.
If you have any questions about this Notice please contact: our Privacy Contact who is Lucinda Jeu.
This Notice of
Privacy Practices describes how we may use and disclose your
protected health information to carry out treatment, payment or
health care operations and for other purposes that are permitted or
required by law. It also describes your rights to access and control
your protected health information. "Protected health information" is
information about you, including demographic information, that may
identify you and that relates to your past, present or future
physical or mental health or condition and related health care
services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website at www.hilliardfamilymedicine.com, calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
1. Uses and Disclosures of Protected
Health Information
Uses and Disclosures of Protected Health Information Based Upon Your
Written Consent
You will be asked
by your physician or their representative to sign a consent form.
Once you have consented to use and disclosure of your protected
health information for treatment, payment and health care operations
by signing the consent form, your physician will use or disclose
your protected health information as described in this Section 1.
Your protected health information may be used and disclosed by your
physician, our office staff and others outside of our office that
are involved in your care and treatment for the purpose of providing
health care services to you. Your protected health information may
also be used and disclosed to pay your health care bills and to
support the operation of the physician's practice.
Following are
examples of the types of uses and disclosures of your protected
health care information that the physician's office is permitted to
make once you have signed our consent form. These examples are not
meant to be exhaustive, but to describe the types of uses and
disclosures that may be made by our office once you have provided
consent.
Treatment:
We will use and disclose your protected health information to
provide, coordinate, or manage your health care and any related
services. This includes the coordination or management of your
health care with a third party that has already obtained your
permission to have access to your protected health information. For
example, we would disclose your protected health information, as
necessary, to a home health agency that provides care to you. We
will also disclose protected health information to other physicians
who may be treating you. For example, your protected health
information may be provided to a physician to whom you have been
referred to ensure that the physician has the necessary information
to diagnose or treat you. In addition, we may disclose your
protected health information from time-to-time to another physician
or health care provider (e.g., a specialist or laboratory) who, at
the request of your physician, becomes involved in your care by
providing assistance with your health care diagnosis or treatment to
your physician.
Payment:
Your protected health information will be used, as needed, to obtain
payment for your health care services. This may include certain
activities that your health insurance plan may undertake before it
approves or pays for the health care services we recommend for you
such as; making a determination of eligibility or coverage for
insurance benefits, reviewing services provided to you for medical
necessity, and undertaking utilization review activities. For
example, obtaining approval for a hospital stay may require that
your relevant protected health information be disclosed to the
health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and marketing activities, and conducting or arranging for other business activities.
For example, we may
disclose your protected health information to medical school
students that see patients at our office. In addition, we may use a
sign-in sheet at the registration desk where you will be asked to
sign your name and indicate your physician. We may also call you by
name in the reception room when your physician is ready to see you.
We may use or disclose your protected health information, as
necessary, to contact you to remind you of your appointment.
We may share your
protected health information with third party "business associates"
that perform various activities (e.g., billing, transcription
services) for the practice. Whenever an arrangement between our
office and a business associate involves the use or disclosure of
your protected health information, we will have a written contract
that contains terms that will protect the privacy of your protected
health information.
We may use or
disclose your protected health information, as necessary, to provide
you with information about treatment alternatives or other
health-related benefits and services that may be of interest to you.
We may also use and disclose your protected health information for
other marketing activities. For example, your name and address may
be used to send you a newsletter about our practice and the services
we offer. We may also send you information about products or
services that we believe may be beneficial to you. You may contact
our Privacy Contact to request that these materials not be sent to
you.
Uses and Disclosures of Protected Health Information Based upon Your
Written Authorization
Other uses and disclosures of your
protected health information will be made only with your written
authorization, unless otherwise permitted or required by law as
described below. You may revoke this authorization, at any time, in
writing, except to the extent that your physician or the physician's
practice has taken an action in reliance on the use or disclosure
indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made
With Your Consent, Authorization or Opportunity to Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Others Involved in
Your Healthcare: Unless you object, we may disclose to a member of
your family, a relative, a close friend or any other person you
identify, your protected health information that directly relates to
that person's involvement in your health care. If you are unable to
agree or object to such a disclosure, we may disclose such
information as necessary if we determine that it is in your best
interest based on our professional judgment. We may use or disclose
protected health information to notify or assist in notifying a
family member, personal representative or any other person that is
responsible for your care of your location, general condition or
death. Finally, we may use or disclose your protected health
information to an authorized public or private entity to assist in
disaster relief efforts and to coordinate uses and disclosures to
family or other individuals involved in your health care.
Emergencies:
We may use or disclose your protected health information in an
emergency treatment situation. If this happens, your physician shall
try to obtain your consent as soon as reasonably practicable after
the delivery of treatment. If your physician or another physician in
the practice is required by law to treat you and the physician has
attempted to obtain your consent but is unable to obtain your
consent, he or she may still use or disclose your protected health
information to treat you.
Communication
Barriers:
We may use and disclose your protected health information if your
physician or another physician in the practice attempts to obtain
consent from you but is unable to do so due to substantial
communication barriers and the physician determines, using
professional judgment, that you intend to consent to use or
disclosure under the circumstances.
Other Permitted and Required Uses and Disclosures That May Be Made
Without Your Consent, Authorization or Opportunity to Object
We may use or
disclose your protected health information in the following
situations without your consent or authorization. These situations
include:
Required By Law:
We may use or disclose your protected health information to the
extent that the use or disclosure is required by law. The use or
disclosure will be made in compliance with the law and will be
limited to the relevant requirements of the law. You will be
notified, as required by law, of any such uses or disclosures.
Public Health:
We may disclose your protected health information for public health
activities and purposes to a public health authority that is
permitted by law to collect or receive the information. The
disclosure will be made for the purpose of controlling disease,
injury or disability. We may also disclose your protected health
information, if directed by the public health authority, to a
foreign government agency that is collaborating with the public
health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight:
We may disclose protected health information to a health oversight
agency for activities authorized by law, such as audits,
investigations, and inspections. Oversight agencies seeking this
information include government agencies that oversee the health care
system, government benefit programs, other government regulatory
programs and civil rights laws.
Abuse or Neglect:
We may disclose your protected health information to a public health
authority that is authorized by law to receive reports of child
abuse or neglect. In addition, we may disclose your protected health
information if we believe that you have been a victim of abuse,
neglect or domestic violence to the governmental entity or agency
authorized to receive such information. In this case, the disclosure
will be made consistent with the requirements of applicable federal
and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings:
We may
disclose protected health information in the course of any judicial
or administrative proceeding, in response to an order of a court or
administrative tribunal (to the extent such disclosure is expressly
authorized), in certain conditions in response to a subpoena,
discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice's premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research:
We may disclose
your protected health information to researchers when their research
has been approved by an institutional review board that has reviewed
the research proposal and established protocols to ensure the
privacy of your protected health information.
Criminal Activity:
Consistent with applicable federal and state laws, we may disclose
your protected health information, if we believe that the use or
disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public. We may
also disclose protected health information if it is necessary for
law enforcement authorities to identify or apprehend an individual.
Military Activity
and National Security:
When the
appropriate conditions apply, we may use or disclose protected
health information of individuals who are Armed Forces personnel (1)
for activities deemed necessary by appropriate military command
authorities; (2) for the purpose of a determination by the
Department of Veterans Affairs of your eligibility for benefits, or
(3) to foreign military authority if you are a member of that
foreign military services. We may also disclose your protected
health information to authorized federal officials for conducting
national security and intelligence activities including for the
provision of protective services to the President or others legally
authorized.
Workers'
Compensation:
We may disclose
your protected health information as authorized to comply with
workers' compensation laws and other similar legally established
programs.
Inmates:
We may use or
disclose your protected health information if you are an inmate of a
correctional facility and your physician created or received your
protected health information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
2.
Your Rights
Following is
a statement of your rights with respect to your protected health
information and a brief description of how you may exercise these
rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. If you elect to have a copy of your record made for you, a charge may be imposed according to our office policy. A "designated record set" contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.
Under federal law,
however, you may not inspect or copy the following records;
psychotherapy notes; information compiled in reasonable anticipation
of, or use in, a civil, criminal, or administrative action or
proceeding, and protected health information that is subject to law
that prohibits access to protected health information. Depending on
the circumstances, a decision to deny access may be reviewable. In
some circumstances, you may have a right to have this decision
reviewed. Please contact our Privacy Contact if you have questions
about access to your medical record.
You have the right to request a restriction of your protected health
information.
This means you may
ask us not to use or disclose any part of your protected health
information for the purposes of treatment, payment or healthcare
operations. You may also request that any part of your protected
health information not be disclosed to family members or friends who
may be involved in your care or for notification purposes as
described in this Notice of Privacy Practices. Your request must
state the specific restriction requested and to whom you want the
restriction to apply.
Your physician is
not required to agree to a restriction that you may request. If
physician believes it is in your best interest to permit use and
disclosure of your protected health information, your protected
health information will not be restricted. If your physician does
agree to the requested restriction, we may not use or disclose your
protected health information in violation of that restriction unless
it is needed to provide emergency treatment. With this in mind,
please discuss any restriction you wish to request with your
physician. You may request a restriction by submitting your request
in writing to our Privacy Contact.
You have the right
to request to receive confidential communications from us by
alternative means or at an alternative location.
We will accommodate
reasonable requests. We may also condition this accommodation by
asking you for information as to how payment will be handled or
specification of an alternative address or other method of contact.
We will not request an explanation from you as to the basis for the
request. Please make this request in writing to our Privacy Contact.
You may have the
right to have your physician amend your protected health
information.
This means you may
request an amendment of protected health information about you in a
designated record set for as long as we maintain this information.
In certain cases, we may deny your request for an amendment. If we
deny your request for amendment, you have the right to file a
statement of disagreement with us and we may prepare a rebuttal to
your statement and will provide you with a copy of any such
rebuttal. Please contact our Privacy Contact to determine if you
have questions about amending your medical record.
You have the right
to receive an accounting of certain disclosures we have made, if
any, of your protected health information.
This right applies
to disclosures for purposes other than treatment, payment or
healthcare operations as described in this Notice of Privacy
Practices. It excludes disclosures we may have made to you, for a
facility directory, to family members or friends involved in your
care, or for notification purposes. You have the right to receive
specific information regarding these disclosures that occurred after
April 14, 2003. You may request a shorter timeframe. The right to
receive this information is subject to certain exceptions,
restrictions and limitations.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
3. Complaints
You may complain to Hilliard Family Medicine, Inc. or to the
Secretary of Health and Human Services if you believe your privacy
rights have been violated by us. You may file a complaint with us by
notifying our privacy contact of your complaint. We will not
retaliate against you for filing a complaint.
You may contact our Privacy Contact, Lucinda Jeu at (614) 876-7330 for further information about the complaint process.
This notice was published and becomes effective on April 14, 2003.
04/14/03
Click here to get the HIPPA Consent form.