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 have questions about this notice or want more information, please contact: Elizabeth Vivona, Privacy Officer at (913)677-4010. The effective date of this notice is May 1, 2013. To appropriately treat you and receive payment for the services we provide, we need to obtain information from you including your full name and address, insurance company, family medical history, current medical history, and current medical condition. We will use and disclose this information and other information we collect in the ways described below. To help you understand how we will use and disclose your information we have put the different uses and disclosures into categories and give examples of each. All of the ways we use or disclose your information will fit into one of the categories listed below, but we cannot list all of the uses and discloses in each category. We may use and disclose your health information for treatment, payment and health care operations.
We may use and disclose your information to provide you with medical treatment and services. Your information may be disclosed to individuals providing care to you and different departments in the hospital. These individuals and departments need your information to provide care, and to coordinate and provide services (such as prescriptions, lab tests, meals, and x-rays). We may also disclose your information to individuals outside the hospital that may be involved in your care after you leave.
We may use and disclose your information to receive payment for the services and treatment provided to you. We use your information to create a bill and disclose your information when we send a bill to your insurance company, you, or a third party. The individual or entity paying the bill may request more information to determine whether the bill is covered by your insurance. We may tell your health plan about a treatment you are going to receive to get approval for payment or to determine whether your health plan will cover treatment.
We may use and disclose your information for health care operation purposes. Health care operations include review of the care you receive for quality assessment, educational, business planning, and compliance plan purposes.
We may provide appointment reminders to you. You may request in writing that we send reminders to a confidential or alternative address.
We may provide you with information about treatment alternatives and other health related benefits and services.
We may also disclose your health information to outside entities without your consent or authorization in the following circumstances:
We disclose information as required by law. For example, we are required to report gunshot wounds to the police.
We disclose information to health agencies as required by law for preventing or controlling disease. Examples are the reporting of sexually transmitted, communicable, and infectious diseases.
We may disclose information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.
Your information may be used by or disclosed to researchers for research approved by a privacy board or an institutional review board.
Your health information may be disclosed to governmental agencies and boards for investigations, audits, licensing, and compliance purposes.
We may be required to disclose your health information to a court or for an administrative proceeding.
We may be required to disclose your information as required by law, pursuant to a court order, warrant, subpoena, or summons.
If you are a member of the armed forces we may release information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.
If you are an inmate of a correctional institution or under the custody of a law enforcement official. This release must be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and the safety of others; or (3) for the safety or security of the correctional institution.
If you are an organ donor, we may release your medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ bank as necessary to facilitate organ or tissue donation.
We may release medical information about you for workers compensation or similar programs.
We may release information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We will give you the opportunity to object to the following uses and discloser of your information.
We may tell your friends, relatives, and other caretakers information which is relevant to their involvement in your care.
We may disclose information about you to public or private agencies for disaster relief purposes.
Except as provided above, we will obtain your written authorization prior to disclosure of your information for any other purpose. Specifically, written authorization is required prior to the disclosure of your information:
We will not use or disclose your psychotherapy notes without a written authorization except as specifically permitted by law.
We will not use or disclose your information for marketing purposes, other than face to face communications with you or promotional gifts of nominal value, without your written authorization.
We will not sell your Protected Health Information without your written authorization, including notification of the payment we will receive.
Where a disclosure is made under your written authorization, you have the right to revoke the authorization at any time. Revocation of an authorization must be in writing. The revocation is effective as of the date you provide it to us and does not affect any prior disclosures made under the authorization. If a state or federal law provides additional restrictions or protections to your information, we will comply with the most stringent requirement.
You have the right to request a restriction on how information about you is used and disclosed. If you want to request a restriction of a use or disclosure of your information, contact our Privacy Officer at the number listed at the beginning of this form. We are required to agree to a request for a restriction related to disclosure of information to your health plan for payment or healthcare operations where you pay for the service in full. We are not otherwise required to agree to any restriction on the use or disclosure of your information.
You have the right to request communications with you be made at an alternative address or phone number. To request that communication be made at a different address or phone number contact our Privacy Officer at the number listed at the beginning of this form to obtain the form to make your request. You have the right to inspect and copy your medical record. To inspect and copy your medical record a request must be made in writing on the form provided by practice. To obtain a form contact our Privacy Officer at the number listed at the beginning of this form.
If you believe the information we have about you is incorrect or incomplete you may request that we amend your medical record. Your request must be made in writing on the form provided by practice. To request a form contact our Privacy Officer at the number listed at the beginning of this form. You have the right to receive an accounting of disclosures, a list of individuals and entities that received your health information for reasons other than treatment, payment, or healthcare operations. You may receive one (1) free accounting during a twelve (12) month period. If you request more than one (1) accounting during a twelve (12) month period, you will be charged a fee. An accounting is not provided for disclosures prior to April 14, 2003.
You have the right to request a paper copy of this notice.
We are required by law to maintain the privacy of Protected Health Information and to provide
individuals with this Notice of our legal duties and privacy practice regarding health information.
We are required to notify you if there is a breach of your unsecured Protected Health Information.
We are required to follow the terms of the current notice.
We may change the terms of this Notice and the revised Notice will apply to all health information in our possession. If we revise this Notice, a copy of the revised Notice will be posted and a copy may be requested from our Privacy Officer at the number listed at the beginning of this form.
If you believe your privacy has been violated you may contact: Elizabeth Vivona, Privacy Officer at (913) 677-4010 or the Office of Civil Rights. You will not be penalized for filing a complaint.20218555v