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Family Medical Center of Hart
County
Notice of Privacy Practices for
Protected Health Information
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 consent, the office is
permitted by federal privacy laws to make uses and disclosures
of your health information for purposes of treatment, payment,
and health care operations. Protected health information is the
information we create and obtain in providing our services to
you. Such information may include documenting your symptoms,
examination and test results, diagnoses, treatment, and applying
for future care or treatment. It also includes billing
documents for those services.
An example of a use of your
health information for treatment purposes is:
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During the course of your
treatment, the physician determines he/she will need to
consult with another specialist in the area. He/she will
share the information with such specialist and obtain their
input.
An example of a use of your
health information for payment purposes is:
-
We submit a claim to your
insurance company. The claim contains health information
about your visit. This health information is required and
used by the insurance company to process the claim.
An example of use of your health
information for health care operations:
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We may obtain services from
business associates such as quality assessment, quality
improvement, outcome evaluation, protocol and clinical
guidelines development, training programs, credentialing,
medical review, legal services, and insurance. We will share
information about you with such business associates as
necessary to obtain these services.
Your
Health Information Rights
The
health and billing records we maintain are the physical property
of Family Medical Center of Hart County. You have the following
rights with respect to your Protected Health Information.
-
Request a restriction on
certain uses and disclosures of your health information by
delivering the request in writing to our office- we are not
required to grant the request but we will comply with any
request granted;
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Obtain a paper copy of the
Notice of Privacy Practices for Protected Health Information
(“Notice’) by making a request at our office.
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Right to inspect and copy
your health record and billing record- you may exercise this
right by delivering the request in writing to our office
using the form we provide to you upon request; appeal a
denial of access to your protected health information except
in certain circumstances;
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Right to request that your
health care record be amended to correct incomplete or
incorrect information by delivering a written request to our
office using the form we provide to you upon request. (The
physician or other health care provider is not required to
make such amendments); you may file a statement of
disagreement if your amendment is denied, and require that
the request for amendment and any denial be attached in all
future disclosures of your protected health information;
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Right to confidential
communication by requesting that communication of your
health information be
made by alternative means or at an alternative location by
delivery the request in writing to our office using the form
we give you upon request; and,
-
If you want to exercise any
of the above rights, please contact Brenda Caswell, HIPAA
Officer, in person or in writing, during normal hours. She
will provide you with assistance on the steps to take to
exercise your rights.
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You have the right to review
this Notice before signing the consent authorizing use and
disclosure of your protected health information for
treatment, payment, and health care operations purposes.
Our
Responsibilities
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Maintain the privacy of your
health information as required by law;
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Provide you with a notice as
to our duties and privacy practices as to the information we
collect and maintain about you:
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Abide by the terms of this
Notice;
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Notify you if we cannot
accommodate a requested restriction or request; and
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Accommodate your reasonable
requests regarding methods to communicate health information
to you.
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Accommodate your request for
an accounting of disclosures.
-
We reserve the right to
amend, change, or eliminate provision in our privacy
practices and access practices and to enact new provisions
regarding the protected health information we maintain. If
our information practices change, we will amend our
“Notice”. You are entitled to receive a revised copy of the
Notice by calling and requesting a copy of our “Notice” or
by visiting our office and picking up a copy.
To
Request Information or File a Complaint
Contact Brenda Caswell, HIPAA
Officer, for questions, additional information, or if you want
to report a problem regarding the handling of your information.
If you believe your privacy
rights have been violated, you may deliver a written complaint
to the above contact at our office OR you may file a complaint
by mailing it to the Region IV, Office for Civil Rights, U.S.
Department of Health and Human Services, Atlanta Federal Center,
Suite 3B70, 61 Forsyth Street, SW., Atlanta, GA 30303-89009,
telephone 404-562-7886, Fax 404-562-7881
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We cannot and will not,
require you to waive the right to file a complaint with the
Secretary of Health and Human Services (HHS) as a condition
of receiving treatment from the office.
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We cannot and will not,
retaliate against you for filing a complaint with the
Secretary of Health and Human Services.
Following
is a List of Other Uses and Disclosures Allowed by the Privacy
Rule
Patient Contact:
We may contact you to provide you with appointment reminders,
information about treatment alternatives, or with information
about other health- related benefits and services that may be of
interest of you. We may contact you as part of a fund raising
effort.
Opportunity to Agree or Object
-Notification: Unless
you object, we may disclose your protected health information in
the following manner:
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Notify or assist in notifying
a family member, personal representative, or other person
responsible for your care, about your location, and about
your general condition, or your death.
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Using our best judgment, we
may disclose to a family member, other relative, close
personal friend, or any other person you identify, health
information relevant to that person’s involvement in your
care or in payment for such care or in an emergency.
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To order to assist in
disaster relief efforts.
Opportunity to Agree or Object
Not Required: We may
use or disclose your protected health information in the
following situations to the extent that the law requires or
allows, without your authorization or giving you an opportunity
to object to the release:
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Public Health Activities:
Controlling
disease, child abuse and neglect, adverse events that are
reportable to the FDA
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Victims of abuse, neglect, or
domestic violence
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Healthcare oversight agencies
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Judicial/Administrative
proceedings
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Law enforcement
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Coroners, medical examiners,
and funeral directors
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Organ Procurement
Organizations
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Institutional Review Board
approved research studies/researchers
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Threat to health and safety
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Specialized governmental
functions
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Correctional institutions
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Workers Compensation
Other Uses and Disclosures
besides those identified in
this Notice will be made only as otherwise authorized by law or
with your written authorization which you may revoke except to
the extent information or action has already been taken.
Website:
We maintain a website that
provides information about our clinic. This notice will be on
the website at
www.munfordvillefmc.com
Effective Date of this Notice:
April 14, 2003
Revised: September 2003, February 28, 2009 |
Privacy Policy