How Medical Information about You May Be Used and Disclosed

We will keep you health care information confidential, using it for the following purposes:

1) Medical Staff – doctors, physician assistants, and nurse practitioners

2) Nursing Staff – registered nurses, licensed practical nurses, and medical assistants.

3) Reception Staff

4) Medical records personnel

We have established standards and procedures that limit various staff members' access to your health information according to their primary job functions. These standards and procedures may change from time to time. All of our staff is required to sign a confidentiality statement. We will share your health care information with other health care providers involved in your care.

1) When we admit you the hospital, we will share your health care information with personnel of that hospital. That hospital will have a privacy and confidentiality policy like this one. If you have questions about their policy, you should ask them.

2) When we refer you to a specialist, we will share your health care information with them. We will send this information whether you actually see a specialist (for example, a surgeon) or whether you do not (for example, if we send a specimen to the laboratory for analysis). That specialist will have a privacy and confidentiality policy like this one. If you have questions about their policy, you should ask them.

3) When we submit laboratory specimen to reference laboratories, and/or pathologists.

We will share your health care information with other people associated with your care at our office. These include:

1) Family members involved in your care

2) Friends you choose to include in your care

3) Other caregivers you choose to involve in your care

4) Other parties actively involved in your care

In this context, these parties include:

1) Our business office staff

2) The insurance organizations involved in your care

3) An organization that mails statements to you

4) If one is required, the collection agency we use to collect unpaid balances.

5) Other firms that become involved in the process of processing or reviewing payment activities.

For Health Care Operations – we will use and disclose your health information to keep practice operable. Examples of this kind of personnel include, but are not

1) Our medical records staff

2) Outside health or management reviewers

3) Individuals performing similar activities limited to, the following:

For Governmental Oversight Activities – if we receive proper instruction from a party with applicable jurisdiction, we will use and disclose your health information to support activities associated with audits, investigations, license reviews, applications for privileges, and in compliance with governmental programs and laws.

As Required by law – we will use and disclose your health care information as required by a court or administrative order, subpoena, discovery request, or other lawful process. We will use and disclose your information by national security, intelligence, and other State and Federal officials, and/or if you are an inmate or otherwise under the custody of law enforcement.

For appointment reminders – we will use and disclose your health information to remind you of appointments you have made in our office or elsewhere.

For Treatment alternatives – we will use and disclose your health information to seek out treatment alternatives for you of which we become aware in the professional or popular literature.

For Research – we will use and disclose your health information to participate in research programs that have proper governmental approval. If your information is to be presented in a format that would allow individual identification, we will seek your written authorization before disclosing it. Upon military command – if you currently serve in the military or are a veteran, we will disclose you information upon proper military command. To prevent a serious threat to health or safety – if a licensed member of our staff determines, in his or her best professional judgment, that there is a serious threat to health or safety of you or some other individual, we will disclose your health information to the proper authorities.

To discharge public health responsibilities – We will disclose you health care information to report deaths, child abuse, neglect, domestic violence, problems with products, reactions to medications, product recalls, disease/infection exposure, and to prevent and control disease, injury, and disability.

Your Individual Rights Regarding Disclosures and Changes to Your Medical Information & Your Access to the Medical Information

Your Privacy Rights

You have the right to:

I nspect and copy your health care information, or that of an individual for whom you are a legal guardian.

(a) If you wish to examine your health care information, you will need to complete and submit the form shown as Exhibit A of this policy. Additional copies are available separately. (b) After we receive the form, we will determine whether to permit you to examine your health care information. In some cases, we may refuse to permit you to do so. Examples of reasons why we would refuse include, but are not limited to, the following: A determination that doing so might harm you, or might harm another person. (c) Unless we decide to refuse permission to review your health care information, we will make an appointment for you to review the information. You will do so in a private room, with a member of our staff available to assist you in finding information. We may charge a fee for this service. (d) While reviewing the information, you will have the right to a copy of parts or all of you health care information. We may charge a fee for this service.

You have the right to amend health care information, if you feel it is inaccurate or incomplete.

(a) To request an amendment to your health care information, complete and submit the form of this policy. Additional copies are available separately. (b) We will review your request to amend your record. We may decide to deny the amendment. Examples of reasons why we would refuse include, but are not limited to, the following: If we feel it is false or misleading, or could harm you or some other person. (c) If we accept your amendment, we will attach it as a permanent document in your health care record. If you make reference, individually and specifically, to specific documents in your health care record, we will append a note to each such document referring a future reader to your amendment. You need to describe each document individually. If you do not identify any particular documents or simply state “all” (or some similar language), then we will add your amendment as a separate document into the chart, but not append notes to any other documents.

You have the right to receive a list of non-routine disclosures we have made of your health care information.

(a) When we refer you to a specialist as described above, we make a routine disclosure of your health care information that we think will be necessary and appropriate for treatment, payment, and health care operations. We do not keep record of these routine disclosures. (b) You can request a list of non-routine disclosures of your health care information we have made. We will provide you a list of these disclosures during subsequent six years, beginning with April 14, 2003. To request a list of these disclosures of your health care information, complete and submit the form shown as Exhibit C of this policy. Additional copies are available separately.

You have the right to request a limit to the health care information we disclose about you.

(a) If you wish to do so, write a letter describing your concerns and wishes to your physician or to our Privacy Officer. (b) We are not obligated to acquiesce to your request. However, if we do agree, we will comply with your requests in all subsequent decisions to use and disclose your care information.

You have the right to request confidential communications.

(a) In general, we will not disclose your care information except as described above. If, however, you wish us to restrict further the parties who will have access to this information, write a letter describing your concerns and wishes to you physician or to our Privacy Officer. (b) We are not obligated to acquiesce to your request. However, if we do agree, we will comply with your requests in all subsequent decisions to use and disclose your health care information.

You have the right to complain.

You have the right to file a complaint with us about our adherence to these policies. (a) Your complaint should be directed to our Privacy Officer. (b) You can either write a letter addressed to the Privacy Officer, or complete and submit the form shown as Exhibit D of this policy. Additional copies are available separately.

You have the right to file a complaint with the Secretary of Health and Human Services

(a) You should write a letter describing your concerns. (b) The letter should be addressed as follows:

Effectiveness and Subsequent Modification

We reserve the right to change this policy, and the associated procedures, without notice.

This policy is effective on and after April 14, 2003. Complete copies are available from the Privacy Officer.