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NOTICE OF PRIVACY PRACTICES
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: Regina Foster at Plaza Primary Care and
Geriatrics. The effective date of this notice is Nov. 17, 2003.
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 coIlect 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 provided 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 disclosures in each category.
We may use and disclose your health information for treatment, payment and health care
operations.
- Treatment: 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 invoIved in your care
after you leave.
- Payment: 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 the 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 the treatment.
- Health Care Operations: We may use and disclose your information for health care
operation purposes. Health care operations includes review of the care you receive
for quality assessment, educational, business planning and compliance plan
purposes.
We may disclose and use your health information and you authorize us to use and disclose
your information for:
- Appointment Reminders: We may provide appointment reminders to you. You may
request in writing that we send reminders to a confidential or alternative address.
- Treatment Alternatives:
We may provide you with information about treatment alternatives and other health-related benefits and services.
We may also disclose your health infonnation to outside entities without your consent or
authorization in the following circumstances:
- Required by Law: We disclose information as required by law. For example, we
are required to report gunshot wounds to the police.
- Public Health Purposes: We disclose information to health agencies as required by
law for preventing or controlling disease. Examples are reporting of sexually
transmitted, communicable and infectious dIseases.
- To Prevent a Serious Threat to Health or Safety: 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.
- Research: Your information maybe used by or disclosed to researchers for research
approved by a privacy board or an institutional review board.
- Health Oversight Activities: Your health information may be disclosed to
governmental agencies and boards for investigations, audits, licensing and
compliance purposes.
- Judicial and Administrative Proceedings: We may be required to disclose your
health information to a court or for an administrative proceeding.
- Law Enforcement Activities: We may be required to disclose your information as
required by law, pursuant to a court order, warrant, subpoena or summons.
- In Emergency Circumstances
- Deceased Individual: We may disclose information for the identification of the body,
or to determine the cause of death.
- Military and Veterans: 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.
- Inmates: 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
safety of others; or (3) for the safety or security of the correctional institution.
- Protective Service for the President and Others
- Organ and Tissue Donation: 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.
- Workers' Compensation: We may release medical information about you for
workers' compensation or similar programs.
- National Security and Intelligence Activities: 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 disclosure of your
information:
- Notification: We may tell your friends, relatives and other caretakers information
which is relevant to their involvement in your care.
- Disaster Relief: We may disclose information about you to public or private agencies
for disaster relief purposes.
Your Rights
- 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 Regina Foster at Plaza Primary Care and Geriatrics.
We are not 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 Regina Foster at Plaza Primary Care and Geriatrics to obtain the form to make your request.
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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
the practice. To obtain a form, contact Regina Foster at Plaza Primary Care and Geriatrics.
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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 the practice. To request a form, contact Regina Foster at Plaza Primary Care and Geriatrics.
- 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-month (12-month) period. lf you request more than one ( 1) accounting, you will be
charged a fee for a one-year (1-year) accounting and for each
additional year up to six (6) years. An accounting is not provided for disclosures
prior to Nov. 17, 2003.
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You have the right to request a paper copy of this Notice.
Our Duties
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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.
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We are required to follow the terms of the current Notice.
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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 Regina Foster at Plaza Primary Care and Geriatrics.
Complaints
If you believe your privacy rights have been violated you may contact:
Regina Foster at Plaza Primary Care and Geriatrics, or the Secretary of the
Department of Health and Human Services. You will not be penalized for filing a complaint.
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