THISNOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSESHOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ CAREFULLY.
Our office is required by lawto maintain the privacy and confidentiality of your protected healthinformation and to provide our patients with notice of our legal duties andprivacy practices with respect to your protected health information.
DISCLOSUREOF YOUR HEALTHCARE INFORMATION
We may disclose yourhealthcare information to other healthcare professionals within our practicefor the purpose of treatment, payment, or healthcare operations.
On occasion, it may benecessary to seek consultation regarding your condition from other healthcareproviders associated with our office. It may be necessary to request recordsfrom other providers who have information or diagnostic testing pertaining toyour health care.
It is our policy to provide asubstitute healthcare provider, authorized by our office to provide assessmentand/or treatment to our patients without advance notice in the event of yourprimary health care provider’s absence due to vacation, sickness, or otheremergency situations.
We may disclose your healthinformation to your insurance provider for the purpose of payment or healthcareoperations.
As a courtesy to ourpatients, we will submit an itemized billing statement to your insurancecarrier for the purpose of payment to our office for healthcare servicesrendered. If you pay for your healthcare services personally we will, as acourtesy and at your request, provide an itemized billing to your insurancecarrier for the purpose of reimbursement to you or provide you with properdocumentation to bill you carrier personally. The billing statement containsmedical information, including diagnosis, date of injury or condition, andcodes which describe the health care services received. Billing statements willbe mailed to the address provided. Unresolved collection issues will be placedwith a collection agency.
We may disclose your healthinformation as necessary to comply with State Worker’s Compensation Laws.
We may disclose your healthinformation to notify or assist in notifying a family member, or another personresponsible for your health about your medical condition in the event of anemergency or your death.
As required by law, we maydisclose your health information to public health authorities for purposesrelated to preventing or controlling disease, injury or disability, reportingchild abuse or neglect, reporting domestic violence, reporting to the Food andDrug Administration problems with products and reactions to medications, andreporting disease or infection exposure.
Judicial and AdministrativeProceedings
We may disclose your healthinformation in the course of any administrative or judicial proceedings.
We may disclose your healthinformation to a law enforcement officer for purposes such as identifying orlocating a suspect, fugitive, material witness or missing person, complyingwith a court order or subpoena, and other law enforcement purposes.
We may disclose your healthinformation to researchers conducting research that has been approved by aninstitutional Review Board.
We may disclose your healthinformation for military, national security, prisoner and government benefitspurposes.
As a courtesy to ourpatients, we may call your home to remind you of your appointment or a missedappointment. We may also call to discuss your account. If you are not at home,we may leave a message on your answering machine or with the person answeringthe phone. No personal information will be disclosed during the recording ormessage other than the date and time of your scheduled appointment along with arequest to call our office if you need to cancel or reschedule yourappointment.
If you refer us to someone,we may send that person a thank you letter and reference your name as thereferral.
Faxing medical information
I specifically giveauthorization to FAX my medical information. I understand that risk is involvedin faxing records and confidentiality at the receiving end cannot always beguaranteed. All faxed information will contain a confidentiality statement andinstructions for returning misdirected information.
Change of Ownership
In the event that our officeis sold or merged with another organization, your health information willbecome the property of the new owner.
Your Health InformationRights
You have the right to requestrestrictions on certain uses and disclosures of your health information. Pleasebe advised, however, that our office is not required to agree to therestriction that you request.
You have the right to haveyour health information received or communicated through an alternative methodor sent to an alternative location other than the usual method of communicationor delivery, upon your request.
You have the right to inspectand copy your health information. All requests for such procedures must be madein writing.
You have the right to requestthat our office amend your protected health information. Please be advised,however, that our office is not required to agree to amend your protectedhealth information. If your request to amend your health information has beendenied, you will be provided with an explanation of our denial reason(s) andinformation about how you can disagree with the denial.
You have a right to receivean accounting of disclosures of your protected health information made by ouroffice.
You have a right to a papercopy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice ofPrivacy Practices
Our office reserves the rightto amend this Notice of Privacy Practices at any time in the future and willmake the new provisions effective for all information that it maintains. Untilsuch amendment is made, our office is required by law to comply with thisnotice. Our office is required by law to maintain the privacy of your healthinformation and to provide you with notice of its legal duties and privacypractices with respect to your health information. If you have any questionsabout any part of this notice or if you want more information about yourprivacy rights, please contact our privacy officer at (480)941-2147. If he/sheis not available, you may make an appointment for a personal conference or bytelephone within 2 working days.
Complaints about your privacyrights or how our office has handled your health information should be directedto our privacy officer by calling this office at (480)941-2147. If he/she isnot available, you may make an appointment for a personal conference in personor by telephone within 2 working days.
If you are not satisfied withthe manner in which this office handles your complaint, you may submit a formalcomplaint to:
DHHS, Office of Civil Rights200 Independence Avenue, SW Room 509F HHH Building Washington, DC 20201