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.

 

WHO WILL FOLLOW THIS NOTICE

 

This notice describes our practice’s procedures and that of:

 

§         Any health care professional authorized to enter information into your medical chart.

 

§         All departments and units of our practice.

 

§         Any member of a volunteer group we allow to help you while you are in our practice.

 

§         All employees, staff, and other practice personnel.

 

 

OUR PLEDGE REGARDING YOUR HEALTH INFORMATION

 

We understand that information about you and your health is personal.  We are committed to protecting your health information.  We create a record of the care and services you receive at our practice, as well as records regarding payment for those services.  We need these records to provide you with quality care and to comply with certain legal requirements.  This notice applies to all of the records of your care generated by our practice doctors and/or staff.

 

This notice will tell you about the ways in which we may use and disclose medical information about you.  We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

 

We are required by law to:

 

§         Make sure that medical information that identifies you is kept private;

 

§         Give you this notice of our legal duties and privacy practices with respect to medical information about you; and

 

§         Follow the terms of the notice that is currently in effect.

 

Page 2 of 9

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

 

If you consent, this 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. 

The following categories describe different ways that we use and disclose health information.  For each category of uses or disclosures, we will explain what we mean and try to give some examples.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

FOR TREATMENT: We may use health information about you obtained by our staff to provide you with medical treatment or services.  We may disclose medical information about you to doctors, nurses, medical assistants, technicians, students, or other personnel who are involved in taking care of you.  Our practice also may share medical information about you in order to coordinate the different things you may need, such as prescriptions and laboratory work.  If during the course of your treatment, the physician determines that he needs to consult with another physician, he will share information about you with that physician and obtain their input on your care.

FOR PAYMENT: We may use and disclose health information about you so that the treatment and services you receive at our practice may be billed, and that payment may be collected from you, an insurance company or another third party.  For example, we may need to give your health plan information about the services that you received at our practice so your health plan will pay us or reimburse you for those services.  We may also tell your health plan about treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

FOR HEALTH CARE OPERATIONS: We may use and disclose medical information about you for health care operations.  These uses and disclosures are necessary to run our practice and to make sure that all patients receive quality care.  For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.  We may also combine medical information about many of our patients to decide what additional services our practice should offer, what services are not needed, and whether certain new treatments are effective.  We may also disclose information to doctors, physician assistants, nurses, medical assistants, technicians, students, and other practice personnel for review and learning purposes.  We may also combine the medical information we have with medical information from other facilities to compare how we are doing and to see where we can make improvements in the care and services we provide.  We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.  We obtain services from our insurers, consultants or other 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 insurers or other business associates as necessary to obtain these services.

Page 3 of 9

OTHER USES AND DISCLOSURES

 

Individuals Involved in Your Care or Payment for Your Care

We may release medical information about you to a friend or family member who is involved in your medical care.  We may also give information to someone who helps pay for your care.  We may also tell your family or friends of your general condition, location or your death.  In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort.

 

Treatment Alternatives/Health Related Services

We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives.  We may also contact you with information about other health-related benefits and services that may be of interest to you.

 

Appointments/Tests

We may use or disclose your protected health information to contact you with appointment reminders or to contact you to schedule appointments or tests that we recommend. We may also contact you to give you results of tests you have had.  We may do this by phone or cell phone, in person or by voice mail/answering machine, mail, e-mail, or by facsimile.  We may contact you at home, work, or other alternative location.

 

As Required By Law

We will disclose medical information about you when required by federal, state, or local law.

 

Serious Threat to Health or Safety

We may use and disclose your protected health information when necessary to prevent or lessen a serious threat to your health and the safety and health of the public or another person.  Such disclosure would be made to a person or organization that may be able to help prevent the threat.

Public Health Risks

We may use and disclose medical information about you for public health activities.  We will disclose protected health information about you to public health or legal authorities for the following types of activities:

§         To prevent or control disease, injury or disability;

§         To report deaths;

§         To report adverse reactions to medications or problems with products;

§         To notify people of recalls of products they may be using;

§         To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease.

Page 4 of 9

Abuse and Neglect

We may use and disclose medical information about you to notify the appropriate government authority if we believe you have been the victim of abuse, neglect or domestic violence.  We will make these disclosures if you agree or when required or authorized by law.

 

Research

We may disclose information about you to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved their research.

 

Health Oversight Activities

We may disclose your protected health information to a health oversight agency for activities authorized by law.  These oversight activities include for example, audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

 

SPECIAL SITUATIONS

 

Organ and Tissue Donation

Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or to other entities engaged in the procurement, banking or transplantation of organs or tissue for the purpose of tissue donation and transplant.

 

Military and Veterans

We may disclose your protected health information if you are a member or former member of the armed forces, as required by military command authorities or by law.  We may also release medical information about foreign military personnel to the appropriate foreign military authority.

 

Workers’ Compensation

If you are seeking compensation through Workers’ Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers’ Compensation or similar programs.

 

Coroners, Medical Examiners, and Funeral Directors

We may disclose your protected health information consistent with applicable laws to coroners, medical examiners and/or funeral directors to allow them to carry out their duties.  This may be necessary, for example, to identify a deceased person or to determine the cause of death.

 

Law Enforcement

We may use and disclose your protected health information if required to do so by law enforcement authorities:

 

§         In response to a court order, subpoena, warrant, summons or similar process;

§         To identify or locate a suspect, fugitive, material witness or missing person;

Page 5 of 9

§         In cases involving felony prosecutions;

§         About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;

§         About a death we believe may be the result of criminal misconduct;

§         About criminal misconduct in a hospital;

§         To the extent that an individual is in the custody of law enforcement; and

§         In emergency situations to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.

 

Judicial/Administrative Proceedings/Lawsuits and Disputes

If you are involved in a lawsuit or dispute, we may disclose your protected health information in response to a court or administrative order.  We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. 

 

National Security and Intelligence Activities

We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

 

Protective Services for the President and Others

We may disclose medical information about you to authorized federal officials so they may provide protection to the President, or other authorized persons or foreign heads of state, or conduct special investigations.

Correctional Institutions

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.  This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; and, (3) for the safety and security of the correctional institution.

Fund Raising

We may use your protected health information to contact you as part of a fund raising effort.

Other Uses and Disclosures

§         Our practice may use a patient sign-in sheet that lists your name, address, and/or phone number.  Other patients may read this sign-in sheet.  The nature of your visit will not be listed on this sign-in sheet.

§         Our staff may call you by name in the waiting room or other locations within the practice.  Other patients may hear your name during your visit to our practice. 

§         Your medical file, with your name on the outside, may, at times, be outside of our file cabinets.  Your name or the file may be identifiable to other persons outside our practice.

Page 6 of 9

§         When a patient checks in or is in the process of checking out after their visit, others standing in close proximity may overhear protected health information.  Efforts to minimize this potential disclosure will be taken.

§         Other uses and disclosures besides those outlined in this notice will be made as otherwise authorized by law or with written authorization by you.  You may revoke the authorization as noted in this policy.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

The health and billing records we maintain are the physical property of this practice.  The information in it, however, belongs to you. You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy

You have the right to inspect and copy medical information that may be used to make decisions about your care.  Usually this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing, using the form we provide, to the practice Privacy Officer at 721 Wellness Way, Suite 100, Lawrenceville, GA 30045.   If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.  We require that any inspection of your medical information will take place during normal business hours, and must be done under the direct observation of a practice Staff Member.

We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed if the denial is made for certain reasons.  Another licensed health care professional chosen by our practice will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome of the review. 

Right to Amend

If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information, but we are not required to make such amendments.  You have a right to request an amendment for as long as we keep the information for our practice.  To request an amendment, your request must be in writing, using the form we provide, and submitted to the practice Privacy Officer at 721 Wellness Way, Suite 100, Lawrenceville, GA 30045. In addition, you must provide a reason and documentation that supports your request.

We may deny your request for an amendment if it is not in writing, on our form, or does not include a reason and documentation to support the request.  In addition, we may deny your request if you ask us to amend information that:

§         Was not created by us, unless the person or entity that created the information is no longer available to make the amendments;

Page 7 of 9

§         Is not part of the medical information kept by or for our practice;

§         Is not part of the information which you would be permitted to inspect and copy or;

§         Is accurate and complete.

Right to an Accounting of Disclosures

You have the right to request an “accounting of disclosures”.  This is a list of certain disclosures we made of medical information about you.

To request this list or accounting of disclosures, you must submit your request in writing, using the form we provide, to the Privacy Officer at 721 Wellness Way, Suite 100, Lawrenceville, GA 30045. Your request must state a time period, which may not start more than six (6) years in the past and may NOT include dates prior to April 14, 2003.  The first list you request within a 12-month period will be at no charge.  For additional lists, we will charge you for the costs of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time, before any costs are incurred.

An accounting may not include internal uses of information for treatment, payment or health care operations, disclosures made to you or made at your request, or disclosures made to family or friends in the course of providing your care.

Right to Request Restrictions

You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations purposes.  You may also request a limit on the medical information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend.  For example, you could ask that we not use or disclose information to your daughter, or that we not use your information in any quality assurance activities.

We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or as required by law.

To request restrictions, you must make your request in writing, using the form we provide, to the Privacy Officer, at 721 Wellness Way, Suite 100, Lawrenceville, GA 30045.
In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; (3) to whom you want the limits to apply, for example disclosures to your spouse; and, (4) the expiration date of your limitations.

Right to Request Confidential Communications

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail.

Page 8 of 9

To request confidential communications, you must make your request in writing, using the form we provide, to the Privacy Officer.  We will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted and how long you want to continue with this form of communication.  If you request that confidential communications occur by certified mail, you agree to pay for costs above those normally associated with delivery of first class mail. 

Right to a Paper Copy of This Notice

You have a right to a paper copy of this notice.  You may ask us to provide you a copy of this notice during normal business hours.

To obtain a paper copy of this notice, contact the Privacy Officer at 721 Wellness Way, Suite 100, Lawrenceville, GA 30045.

Right to Revoke Authorizations Made Previously

If you provide us permission to use or disclose medical information about you, you may revoke that authorization by making your request in writing, using the form we provide, and delivering it to the Privacy Officer at 721 Wellness Way, Suite 100, Lawrenceville, GA 30045. If you revoke your permission, we may no longer use or disclose medical information about you for the reasons covered by your written revocation of authorization to release information about you.

You understand that we are unable to retrieve any disclosures we have already made with your prior permission, and that we are required to retain our records of the care that we provided you.

If you wish to exercise any of these rights, you may contact the Privacy Officer at 721 Wellness Way, Suite 100, Lawrenceville, GA 30045 during normal business hours.  The Privacy Officer will help explain these rights and what you must do to exercise them. 

CHANGES TO THIS NOTICE

We reserve the right to amend, change or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain.  We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive about you in the future.  If our information practices change, we will amend our notice.  The notice will contain, on the first page, in the top right-hand corner, the effective date.

You are entitled to a revised copy of the notice by requesting, in person, at our office at 721 Wellness Way, Suite 100, Lawrenceville, GA 30045 , a copy of our “Notice”.  We are not required to notify you individually of changes made to this notice.  We will post a copy of the current notice in our practice. 

COMPLAINTS

If you have questions, would like additional information, or want to report a problem regarding handling of your information, you may contact the practice Privacy Officer at 721 Wellness Way, Suite 100, Lawrenceville, GA 30045 .

Page 9 of 9

If you believe your privacy rights have been violated, you may file a written complaint, using the form we provide, and by delivering your written complaint to our Privacy Officer.  You may also file a complaint by mailing it to the Secretary of Health and Human Services.  You will not be penalized by our practice for filing a complaint. 

METHODS OF DISCLOSURE

The practice may use and disclose protected health information by different methods.  Some, but not all, of these methods include distribution by:

§         Facsimile;

§         First class and/or certified mail;

§         Phone, answering machines, cell phones and;

§         Using a voice mail system.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to use will be made only with your written permission.