HIPAA Notice of Privacy Practices
Center for Advanced Therapeutic Endoscopy
880
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW CAREFULLY.
This Notice of Privacy Practices describe how we may
use and disclose your protected health information (PHI) to carry out
treatment, payment or health care operation (TPO) and for other purposes that
are permitted or required by law. It also describes your right 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
mental health or condition and related health care services.
Uses and Disclosure of Protected Health Information:
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, to pay your health care bills, to support the
operations of the physicians practice, and any other use required by law.
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. For
example, we will disclose your protected health information as necessary, to a
home health agency that provides care to 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.
Payment: Your
protected health information will be used, as needed to obtain payment for your
health care services. 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 physicians
practice. These activities include, but are not limited to, qualify
assessment activities, employee review activities, training of medical
students, licensing, 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 waiting 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 use of disclose your protected health
information in the following situation without your authorization. These
situations include: as Required By Law Public Health issues as required by law,
Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug
Administration requirement: Legal Proceedings: Law Enforcement: Coroners,
Funeral Directors, and Organ Donation: Research: Criminal Activity: Military
Activity and National Security: Workers’ Compensation: Inmates: Required
Uses and Disclosures: Under the law we must make disclosure to you and when
required by the Secretary of Department of Health and Human Services to
investigate or determine out compliance with the requirement of Section
164-500.
Other Permitted and Required Uses and Disclosure Will
Be Made Only With Your Consent, Authorization or
You may revoke this authorization, at any time, in
writing, except to the extent that your physician or the physician’s
practice has taken action in reliance on the use or disclosure indicated in the
authorization.
Your Rights
Following is a statement of your rights with respect to
your protected health information.
You have the right to inspect and copy your protected
health information. Under the federal
law however you may not inspect or copy the following records; psychotherapy
notes; information compiled in reasonable anticipation of, or use in, civil,
criminal, or administrative action or proceeding, and protected health
information that is subject to law that prohibits access to protected health
information.
You have the right to request a restriction of
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 of healthcare
operations. You may also request that any part of your protected health
information not be disclose 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 believe it is in your best
interest to permit use and disclosure of your protected health information,
your protected health information will not be restricted. You then have
the right to use another Healthcare Professional.
You have right to request to receive confidential communication
from us by alternative means or at an alternative location. You have the
right to obtain a paper copy of the notice from us, upon request even if you have agreed to accept this
notice alternatively i.e. electronically.
You may have the right to have your physician amend
your protected health information. 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.
You have the right to receive an accounting of certain
disclosures we have made, if any of your protected health information.
We reserve the right to change the terms of this notice
and will inform you by mail of any changes. You then have the right to
object or withdraw as provided in this notice.
Complaints
You may complain to us 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.
We are required by law to maintain the privacy of, and
provide individuals with this notice of our legal duties and privacy practices
with respect to protected health information. If you have any objections
to this form, please ask to speak with our HIPPA Compliance officer in person
or by phone at our Main Phone Number.
Signature below is only acknowledgement that you have
received this Notice of out Privacy Practice:
Print Name:
______________________________________________________ Signature
____________________________________________ Date _____/_____/______