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.
We are required under the federal health care privacy rules (the "Privacy
Rules"), to protect the privacy of your health information, which includes
information about your health history, symptoms, test results, diagnoses, treatment,
and claims and payment history (collectively, "Health Information").
We are also required to provide you with this Privacy Notice regarding our legal
duties, policies and procedures to protect and maintain the privacy of your Health
Information. We are required to follow the terms of this Privacy Notice unless
(and until) it is revised. We reserve the right to change the terms of this Privacy
Notice and to make the new notice provisions effective for the Health Information
that we maintain and use, as well as for any Health Information that we may receive
in the future. Should the terms of this Privacy Notice change, we will promptly
distribute a revised copy of the notice to you. Revised Privacy Notices will
be available at our office for individuals to take with them and we will post
a copy of revised Privacy Notices in a prominent location in our office.
PERMITTED USES AND DISCLOSURES OF YOUR HEALTH INFORMATION.
1. Uses and Disclosures Which Require Patient Consent
Under the Privacy Rules, we are permitted with your written Consent to use and
disclose your Health Information
for the following purposes: •Treatment: We are permitted to use and disclose your
Health Information in the provision and coordination of your health care. For
example, we may disclose your Health Information to your primary health care
provider, consulting providers, and to other health care personnel who have a
need for such information for your
care and treatment. •Payment: We are permitted to use and disclose your Health
Information for the purposes of determining coverage, billing, and reimbursement.
This information may be released to an insurance company, third party payor,
or other authorized entity or person involved in the payment of your medical
bills and may include copies or portions of your medical record which are necessary
for payment of your bill. For example, a bill sent to your insurance company
may include information that identifies you, your diagnosis, and the procedures
and supplies used in
your treatment. •Health Care Operations: We are permitted to use and
disclose your Health Information during our health care operations, including,
but not limited to: quality assurance, auditing, licensing or credentialing activities,
and for educational purposes. For example, we can use your Health Information
to internally assess our quality
of care provided to patients.
2. Uses and Disclosures Which Require Patient Opportunity to Verbally
Agree or
Object
Under the Privacy Rules, we are permitted to use and disclose your Health Information:
(i) for the creation of facility directories, (ii) to disaster relief agencies,
and (iii) to family members, close personal friends or any other person identified
by you, if the information is directly relevant to that person's involvement
in your care or treatment. Except in emergency situations, you will be notified
in advance and have the opportunity to verbally agree or object to this use and
disclosure of your Health Information.
3. Uses and Disclosures Which Require Written Authorization
As required by the Privacy Rules, all other uses and disclosures of your Health
Information (not described above) will be made only with your written Authorization.
For example, in order to disclose your Health Information to a company for marketing
purposes, we must obtain your Authorization. Under the Privacy Rules, you may
revoke your Authorization at any time. The revocation of your Authorization will
be effective immediately, except to the extent that: we have relied upon it previously
for the use and disclosure of your Health Information; if the Authorization was
obtained as a condition of obtaining insurance coverage where other law provides
the insurer with the right to contest a claim under the policy or the policy
itself; or where your Health Information was obtained as part of a research study
and is necessary to maintain the integrity of the study. [Describe any other
uses or disclosures
pursuant to an Authorization.]
Uses and Disclosures Which Do Not Require Consent, Authorization or Opportunity
to Verbally Agree or Object.
Under the Privacy Rules, we are permitted to use or disclose your Health Information
without your Consent, Authorization or Opportunity to Verbally Agree or Object
with regard to the following:
• Uses and Disclosures Required by Law: We may use and
disclose your Health Information when required to do so by law, including, but
not limited to: reporting abuse, neglect and domestic violence; in response to
judicial and administrative proceedings; in responding to a law enforcement request
for information; or in order to alert law enforcement to criminal conduct on
our premises or of a death that may be
the result of criminal conduct.
• Public Health Activities: We may disclose your Health
Information for public health reporting, including, but not limited to: child
abuse and neglect; reporting communicable diseases and vital statistics; product
recalls and adverse events; or notifying person(s) who may have been exposed
to a disease or are at risk
of contracting or spreading a disease or condition.
• Abuse and Neglect: We may disclose your Health Information
to a local, state, or federal government authority, if we have a reasonable belief
of abuse, neglect
or domestic violence.
• Regulatory Agencies: We may disclose your Health Information
to a health care oversight agency for activities authorized by law, including,
but not limited to, licensure, investigations and inspections. These activities
are necessary for the government and certain private health oversight agencies
to monitor the health care system, government programs, and compliance with civil
rights.
• Judicial and Administrative Proceedings: We may disclose
your Health Information in judicial and administrative proceedings, as well as
in response to an order of a court, administrative tribunal, or in response to
a subpoena, summons, warrant,
discovery request, or similar legal request.
• Law
Enforcement Purposes: We may disclose your Health Information to law
enforcement
officials when required to do so by law.
• Coroners,
Medical Examiners, Funeral Directors: We may disclose your Health Information
to a coroner or medical examiner. This may be necessary, for example, to determine
a cause of death. We may also disclose your health information to funeral directors,
as necessary, to carry out their duties.
• Research:Under certain circumstances, we may disclose
your Health Information to researchers when their clinical research study has
been approved and where certain safeguards are in place to ensure the privacy
and protection of your
Health Information.
• Threats
to Health and Safety: We may use or disclose your Health Information
if we believe, in good faith, that the use or disclosure is necessary to prevent
or lessen a serious or imminent threat to the health or safety of a person or
the public, or is necessary for law enforcement to identify or apprehend an individual.
• Specialized
Government Functions: If you are a member of the U.S. Armed Forces,
we may disclose your Health Information as required by military command authorities.
We may also disclose your Health Information to authorized federal officials
for national security reasons and the Department of State for medical suitability
determinations.
• Inmates: If you are an inmate of a correctional institution
or under the custody of a law enforcement official, we may release your Health
Information to the correctional institution or law enforcement official, where
such information is necessary for the institution to provide you with health
care; to protect your health or safety, or the health or safety of others; or
for the safety and
security of the correctional institution.
• Workers'
Compensation: We may disclose your Health Information to your employer
to the extent necessary to comply with Alabama laws relating to workers' compensation
or other similar programs.
• Fundraising: We may use or disclose your Health Information
to make a fundraising communication to you, for the purpose of raising funds
for our own benefit. Included in such fundraising communications will be instructions
describing how you may
ask not to receive future communications.
• Marketing: We may use or disclose your Health Information
to make a marketing communication to you that occurs in a face-to-face encounter
with us
or which
concerns a promotional gift of nominal value provided by us.
• Appointment
Reminders/Treatment Alternatives: We may use and disclose your Health
Information to remind you of an appointment for treatment and medical care at
our office or to provide you with information regarding treatment alternatives
or other health-related benefits and services that may be of interest to you.
• Business
Associates: We may disclose your Health Information to business associates
who provide services to us. Our business associates are required to protect the
confidentiality of your Health Information.
• Other Uses and Disclosures: In addition to the reasons
outlined above, we may use and disclose your Health Information for other purposes
permitted
by the
Privacy Rules.
PATIENT RIGHTS
You have the following rights concerning your Health Information:
1. Right to Inspect and Copy Your Health Information
Upon written request, you have the right to inspect and copy your own Health
Information contained in a
designated record set, maintained by or for us. A "designated record set" contains
medical and billing records and any other records that we use for making decisions
about you. However, we are not required to provide you access to all the Health
Information that we maintain. For example, this right of access does not extend
to psychotherapy notes, or information compiled in reasonable anticipation of,
or for use in, a civil, criminal or administrative proceeding. Where permitted
by the Privacy Rules, you may request that certain denials to inspect and copy
your Health Information be reviewed. If you request a copy or summary of explanation
of your Health Information, we may charge you a reasonable fee for copying costs,
including the cost of supplies and labor, postage, and any other associated costs
in preparing the summary or explanation.
2. Right to Request Restrictions on the Use and Disclosure of Your Health
Information
You have the right to request restrictions on the use and disclosure of your
Health Information for treatment, payment and health care operations, as well
as disclosures to persons involved in your care or payment for your care, such
as family members or close friends. We will consider, but do not have to agree
to, such requests.
3. Right to Request an Amendment of Your Health Information
You have the right to request an amendment of your Health Information. We may
deny your request if we determine that you have asked us to amend information
that: was not created by us, unless the person or entity that created the information
is no longer available; is not Health Information maintained by or for us; is
Health Information that you are not permitted to inspect or copy; or we determine
that the information is accurate and complete. If we disagree with your requested
amendment, we will provide you with a written explanation of the reasons for
the denial, an opportunity to submit a statement of disagreement, and a description
of how you may file
a complaint.
4. Right to an Accounting of Disclosures of Your Health Information
You have the right to receive an accounting of disclosures of your Health Information
made by us within six (6) years prior to the date of your request. The accounting
will not include: disclosures related to treatment, payment or health care operations;
disclosures to you; disclosures based on your Authorization; disclosures that
are part of a Limited Data Set; incidental disclosures; disclosures to persons
involved in your care or payment for your care; disclosures to correctional institutions
or law enforcement officials; disclosures for facility directories; or disclosures
that occurred prior to April 14, 2003.
5. Right to Alternative Communications
You have the right to receive confidential communications of your Health Information
by a different means or at a different location than currently provided. For
example, you may request that we only contact
you at home or by mail.
6. Right to Receive a Paper Copy of this Privacy Notice
You have the right to receive a paper copy of this Privacy otice upon request,
even if you have agreed
to receive this Privacy Notice electronically.
If you want to exercise any of these rights, please contact our Privacy Officer.
All requests must be submitted to us in writing on a designated form (which we
will provide to you), and returned to the attention of our Privacy Officer at
the address below.
CONTACT INFORMATION AND HOW TO REPORT A PRIVACY RIGHTS VIOLATION
If you have questions and/or would like additional information regarding the
uses and disclosures of your Health Information, you may contact our Privacy
Officer at:
If you believe that your privacy rights have been violated or that we have violated
our own privacy practices, you may file a complaint with us. You may also file
a complaint with the Secretary of the U.S. Department of Health and Human Services
at 200 Independence Avenue, S.W., Washington, D.C. 20201. Complaints filed directly
with the Secretary must be made in writing, name us, describe the acts or omissions
in violation of the Privacy Rules or our privacy practices, and must be filed
within 180 days of the time you knew or should have known of the violation. Complaints
submitted directly to us must be in writing and to the attention of our Privacy
Officer. There will be no retaliation for filing a complaint.
The Effective Date of this Privacy Notice is July 21, 2003.
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