THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE READ IT CAREFULLY.
NOTICE OF PRIVACY POLICY
EFFECTIVE APRIL 14TH, 2003
The following is the privacy
policy (“Privacy Policy”) of Family Physicians/Valley After Hours Clinic
(“Covered “Entity”) as described in the Health Insurance Portability and
Accountability Act of 1996 and regulations promulgated there under, commonly
known as HIPAA. HIPAA requires
Family Physicians/Valley After Hours Clinic by law to maintain the privacy of
your personal health information and to provide you with notice of Family
Physicians/Valley After Hours Clinic legal duties and privacy policies with
respect to your personal health information.
We are required by law to abide by the terms of this Privacy Notice.
We collect personal health information from you through treatment, payment and related healthcare operations, the application and enrollment process, and/ or healthcare providers or health plans, or through other means, as applicable. Your personal health information that is protected by law broadly includes any information, oral, written or recorded, that is created or received by certain health care entities, including health care providers, such as physicians and hospitals, as well as, health insurance companies or plans. The law specifically protects health information that contains data, such as your name, address, social security number, and others, that could be use to identify you as the patient who is associated with that health information.
Generally, we may not use or disclose your
personal health information without your permission. Further, once your permission has been
obtained, we must use or disclose your personal health information in
accordance with the specific terms of that permission. The following are the circumstances under
which we are permitted by law to use or disclose your personal health
information.
Without Your Consent
Without your consent, we may use or disclose
your personal health information in order to provide you with services and the
treatment you require or request, or to collect payment for those services, and
to conduct other related health care operations otherwise permitted or required
by law. Also, we are permitted to
disclose your personal health information within and among our workforce in
order to accomplish these same purposes.
However, even with your permission, we are still required to limit such
uses or disclosures to the minimal amount of personal health information that
is reasonably required to provide those services or complete those activities.
Examples of treatment
activities include: (a) the provision, coordination, or management of
health care and related services by health care providers; (b) consultation
between health care providers relating to a patient; or (c) the referral
of a patient for health care from one
health care provider to another.
Examples of payment
activities include: (a) billing and collection activities and related data
processing; (b) actions by a health plan or insurer to obtain premiums or to
determine or fulfill its responsibilities for coverage and provision of
benefits under its health plan or insurance agreement, determinations of
eligibility or coverage, adjudication or subrogation of health benefit claims;
(c) medical necessity and appropriateness of care reviews, utilization review
activities, and (d) disclosure to consumer reporting agencies of information
relating to collection of premiums or reimbursement.
Examples of health care
operations include: (a) development of clinical guidelines; (b) contacting
patients with information about treatment alternatives or communications in
connection with case management or care coordination; (c) reviewing the
qualifications of and training health care professionals; (d) underwriting and
premium rating; (e) medical review, legal services, and auditing functions; and
(f) general administrative activities such as customer service and data
analysis.
As Required By Law
We may use or disclose your
personal health information to the extent to use or disclose is required by law
and the use or disclosure complies with and is limited to the relevant
requirements of such law. Examples of
instances in which we are required to disclose your personal health information
include: (a) public health activities including, preventing or controlling
disease or other injury, public health surveillance or investigations,
reporting adverse events with respect to food or dietary supplements of product
defects or problems to the Food and Drug Administration, medical surveillance
of the workplace or to evaluate whether the individual has a work-related
illness or injury in order to comply with Federal or state law; (b) disclosures
regarding victims of abuse, neglect, or domestic violence including, reporting
to social service or protective services agencies; (c) health oversight activities
including, audits, civil, administrative, or criminal investigations,
inspections, licensure or disciplinary actions, or civil, administrative,
or criminal proceedings or actions, or
other activities necessary for appropriate oversight of government benefit
programs; (d) judicial and administrative proceedings in response to an order
of a court or administrative tribunal, a warrant, subpoena, discovery request,
or other lawful process; (e) law enforcement purposes for the purpose of
identifying or locating a suspect, fugitive, material witness, or missing
person, or reporting crimes in emergencies, or reporting a death; (f)
disclosures about decedents for purposes of
donation of organs, eyes or tissue; (g) for research purposes under
certain conditions; (h) to avert a serious threat to health or safety’ (i)
military and veterans activities; (j) national security and intelligence
activities, protective services of the President and others; (k) medical
suitability determinations by entities that are components of the Department of
State; (l) correctional institutions and other law enforcement custodial
situations; (m) covered entities that are government programs providing public
benefits, and for workers’ compensation.
All Other Situations, With
Your Specific Authorization
Except as otherwise permitted or
required, as described above, we may not use of disclose your personal health
information without your written authorization.
Further, we are required to use or disclose your personal health information
consistent with the terms of your authorization. You may revoke your authorization to use or
disclose any personal health information at any time, except to the extent that
we have taken action in reliance on such authorization, or, if you provided the
authorization as a condition of obtaining insurance coverage, other law
provides the insurer with the right to contest a claim under the policy.
Miscellaneous Activities,
Notice
We may contact you to provide appointment
reminders or information about treatment alternatives or other health-related
benefits and services that may be of interest to you.
Your Rights With Respect to
Your Personal Health Information
Under HIPAA, you have certain rights with
respect to your personal health information.
The following is a brief overview of your rights and our duties with
respect to enforcing those rights.
Right To Request Restrictions
On Use Or Disclosure
You have the right to request restrictions on
certain uses and disclosures of your personal health information about
yourself. You may request
restrictions on the following uses or disclosures; to carry out treatment, payment, or healthcare
operations; (b) disclosures to family members, relatives, or close personal
friends of personal health information directly relevant to your care or
payment related to your health care, or your location, general condition, or
death; (c) instances in which you are not present or your permission cannot
practicably be obtained due to your incapacity or an emergency circumstance;
(d) permitting other persons to act on your behalf to pick up filled
prescriptions, medical supplies, X-rays, or other similar forms of personal
health information; or (e) disclosure to a public or private entity authorized
by law or by its charter to assist in
disaster relief efforts.
While we are not required to
agree to any requested restriction, if we agree to a restriction, we are bound
not to use or disclose your personal healthcare information in violation of
such restriction, except in certain emergency situations. We will not accept a request to restrict uses
or disclosures that are otherwise required by law.
Right To Receive Confidential
Communications
You have the right to receive confidential
communications of your personal health information. We may require written requests. We may condition the provision of
confidential communications on you providing us with information as to how
payment will be handled and specification of an alternative address or other
method of contact. We may require that a
request contain a statement that disclosure of all or a part of the information
to which the request pertains could endanger you. We may not require you to provide an
explanation of the basis for your request as a condition of providing
communications to you on a confidential basis.
We must permit you to request and must accommodate reasonable requests
by you to receive communications of personal health information from us by
alternative means or at alternative locations.
If we are a health care plan, we must permit you to request and must
accommodate reasonable requests by you to receive communications of personal
health information from us by alternative means or at alternative locations if
you clearly state that the disclosure of all or part of that information could
endanger you.
Right To Inspect And Copy
Your Personal Health Information
Your designated record set is a group of
records we maintain that includes Medical records and billing records about
you, or enrollment, payment, claims adjudication, and case or medical
management records systems, as applicable.
You have the right of access in order to inspect and obtain a copy your
personal health information contained in you designated record set, except
for (a) psychotherapy notes, (b) information complied in reasonable
anticipation of, or for use in, a civil, criminal, or administrative action or
proceeding, and (c) health information maintained by us to the extent to which
the provision of access to you would be prohibited by law. We may require written requests. We must provide you with access to your
personal health information in the form or format requested by you, if it is
readily producible in such form or format, or, if not, in a readable hard copy
form or such other form or format. We
may provide you with a summary of the personal health information requested, in
lieu of providing access to the personal health information or may provide an
explanation of the personal health information to which access has been provided,
if you agree in advance to such a summary or explanation and agree to the fees
imposed for such summary or explanation.
We inspect or obtain copies of your personal health information or
mailing a copy to you at your request.
We will discuss the scope, format, and other aspects of your request for
access as necessary to facilitate timely access. If you request a copy of your personal health
information or agree to a summary or explanation of such information, we charge
a reasonable cost-based fee for copying, postage, if you request a mailing, and
the costs of preparing an explanation or summary as agreed upon in advance. We
reserve the right to deny you access to and copies of certain personal health
information as permitted or required by law. We will reasonably attempt to accommodate any
request for personal health information by, to the extent possible, giving you
access to other personal health information after excluding the information as
to which we have a ground to deny access.
Upon denial of a request for access or request for information, we will
provide you with a written denial specifying the legal basis for denial, a
statement of your rights, and a description of how you may file a complaint
with us. If we do not maintain the information
that is the subject of your request for access but we know where the requested
information is maintained, we will inform you of where to direct your request
for access.
Right To Amend Your Personal
Health Information
You have the right to request that we amend
your personal health information or a record about you contained in your
designated record set, for as long as the designated record set is maintained
by us. We have the right to deny your
request for amendment, if: (a) we determine that the information or record that
is the subject of the request was not created by us, unless you provide a
reasonable basis to believe that the originator of the information is no longer
available to act on the requested amendment, (b) the information is not part of
your designated record set maintained by us, (c) the information is prohibited
from inspection by law, or (d) the information is accurate and complete. We may require that you submit written
requests and provide a reason to support the requested amendment. If we deny your request, we will provide you
with a written denial stating the basis of the denial, your right to submit a
written statement disagreeing with the denial, and a description of how you may
file a complaint with us or the Secretary of the U.S. Department of Health and
Human Service (DHHS). This denial will
also include a notice that if you do not submit a statement of disagreement,
you may request that we include your request for amendment. Copies of all
requests, denials, and statements of disagreement will be included in your
designated record set. If we accept your
request for amendment, we will make reasonable efforts to inform and provide
the amendment within a reasonable time to persons identified by you as having
received personal health information of yours prior to amendment and persons
that we know have the personal health information that is the subject of the
amendment and that may have relied, or could foreseeable rely, on such
information to your detriment. All
requests for amendment shall be sent to Family Physicians or Valley After Hours
Clinic at 14 Medical Park Valley,
Right To Receive An Accounting Of Disclosures Of Your Personal Health
Information
Beginning April 14, 2003, you have the right to receive a
written accounting of all disclosures of your personal health information that
we have made within the six (6) year period immediately preceding the date on
which the accounting is requested. You
may request an accounting of disclosures for a period of time less than six (6)
years from the date of the request. Such
disclosures will include the date of each disclosure, the name and, if known,
the address of the entity or person who received the information, a brief
description of the information disclosed, and a brief statement of the purpose
and basis of the disclosure or, in lieu of such statement, a copy of your
written authorization or written request for disclosure pertaining to such
information. We are not required to
provide accounting of disclosures for the following purposes: (a)
treatment, payment, and healthcare operations, (b) disclosures pursuant to your
authorization, (c) disclosures to you, (d) for a facility directory or to
persons involved in your care, (e) for national security or intelligence
purposes, (f) temporarily suspend your right to receive an accounting of
disclosures to health oversight agencies or law enforcement officials, as
required by law. We will provide the
first accounting to you in any twelve (12) month period without charge, but
will impose a reasonable cost-based fee for responding to each subsequent
request for accounting within that same twelve (12) month period. All requests for an accounting shall be sent
to Family Physicians or Valley After Hours Clinic at 14 Medical Park Valley,
Complaints
You may file a complaint with us and with the
Secretary of DHHS if you believe that your privacy rights have been
violated. You may submit your complaint
in writing by mail or electronically to our privacy officer, at 14 Medical
Park Valley,
(334)
756-4136 or office@valleyfamilyphysicians.com. A complaint must name the entity that is the
subject of the complaint and describe the acts or omissions believed to be in
violation of the applicable requirements of HIPAA of this Privacy Policy. A complaint must be received by us or filed
with the Secretary of DHHS within 180 days of when you knew or should have known
that the act or omission complained of occurred. You will not be retaliated against for filing
any complaint.
We reserve the right to
revise or amend this Privacy Policy at any time. These revisions or amendments may be made
effective for all personal health information we maintain even if created or
received prior to the effective date of the revision or amendment. We will provide you with notice of any
revisions or amendments to this Privacy Policy, or changes in the law affecting
this Privacy Notice, by mail or electronically within 60 days of the effective
date of such revision, amendment, or change.
We will provide you with a copy of the most
recent version of the Privacy Policy at any time upon your written request sent
to Family Physicians or Valley After Hours Clinic at 14 Medical Park Valley,
AL 36854 or at the following
website address: office@valleyfamilyphysicians.com. For any other requests or for further information
regarding the privacy of your personal health information, and for information
regarding the filing of a complaint with us, please contact our privacy officer
at the address, telephone number, or e-mail address listed above.
I HAVE RECEIVED A COMPLETE COPY OF THE APRIL 14, 2003
NOTICE OF PRIVACY POLICY FROM FAMILY PHYSICIANS/VALLEY AFTER HOURS CLINIC AND
DO HEREBY AGREE WITH THIS POLICY AS SET
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PATIENTS NAME (Print) DATE
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PATIENTS DOB S.S.
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PATIENTS SIGNATURE
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