HIPAA Guidelines
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 THIS
NOTICE CAREFULLY AND SIGN THE BACK PAGE.
This Notice describes how Atrium OB/GYN may use and
disclosure your protected health information. The terms of this Notice
of Privacy Practices are effective April 14, 2003. This office will
share patient health information as is necessary to provide quality
health care and receive reimbursement for those services as permitted
by law. This office is required by law to maintain the privacy of our
patients' health information and to provide patients with this Notice
of Privacy Practices. This office will abide by the terms of this
Notice so long as it remains in effect and we reserve the right to
change the terms of this Notice of Privacy Practices as necessary. A
copy of any revised notices will be available in this office, or, upon
request to Privacy Officer, 4151 Holiday Street NW, Canton, OH 44718.
USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
This office is committed to maintain the
confidentiality of your health information. However, your health
information may be used and disclosed as customary and reasonable for
purposes of treatment, payment, and health care operations and
pursuant to a signed authorization form.
You have the right to revoke that authorization in writing
unless any action has been taken in reliance on the authorization.
Treatment, Payment,
and Health Care Operations. [Except
as otherwise provided, or with your signed consent,] This office will
use and disclosure your health information for purposes of treatment,
payment, and as otherwise necessary and permitted by law, for our
health care operations. This
may include disclosure to another health care provider who, at the
request of your physician, becomes involved in your treatment, or for
purposes of approval of reimbursement from your health plan.
Business
Associates. At
times, it may be necessary for us to provide your health information
to certain outside persons or organizations that assist us with our
health care operations, such as auditing, accreditation, legal
services, etc. These
business associates are required to properly safeguard the privacy of
your health information.
Family
and Friends. With
your approval and using our professional judgment, your health
information may be disclosed to designated family and others who are
directly involved in your care or in payment of your care. If you are
unavailable, incapacitated, or in an emergency medical situation, and
we determine that a limited disclosure may be in your best interest,
we may share limited health information with such individuals without
your approval.
Appointments
and Services. This
office may contact you and leave a message on your answering machine
to provide appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be
of interest to you. You have the right to request, and we will
accommodate your reasonable requests, to receive communications
regarding your health information from us by alternative means or at
alternative locations. You may request such confidential communication
in writing to Privacy Officer, 4151 Holiday Street NW, Canton, OH
44718.
Other uses and disclosures of your individual health information, permitted or required by law, may be made without your consent or authorization.
1.
Use or disclosure of your health information for any purpose
required by law;
2.
Use or disclosure of your health information for public health
activities, such as required reporting of disease, injury, and birth
and death, and for required public health investigations;
3.
Use or disclosure of your health information as required by law
if we suspect child abuse or neglect; we may also release your
individual health information as required by law if we believe you are
a victim of abuse, neglect, or domestic violence;
4.
Use or disclosure of your health information, if necessary, to
the Food and Drug Administration;
5.
Use or disclosure of your health information to your employer
when we have provided health care to you at the request of your
employer;
6.
Use or disclosure of your health information if required by law
to a government oversight agency conducting audits, investigations, or
civil or criminal proceedings;
7.
Use or disclosure of your health information if required by a
court or administrative ordered subpoena or discovery request; in most
cases you will have notice of such release;
8.
Use or disclosure of your health information to law enforcement
officials;
9.
Use or disclosure of your health information to coroners and/or
funeral directors consistent with law;
10.
Use or disclosure of your health information to arrange an
organ or tissue donation or transplant;
11. Use or disclosure of your health information if you are a member of the military as required by armed forces services; we may also release your individual health information if necessary for national security or intelligence activities
12. Use or disclosure of your health information to workers' compensation agencies.
YOUR RIGHTS
1. Restrictions
on Use and Disclosure of Individual Health Information. You have the right to
request restrictions on some of our uses and disclosures of your
health information. These
restrictions must be made in writing and signed by you or your
representative. This office is not required to agree to your
restrictions. We retain the right to terminate an agreed-to
restriction if we believe such termination is appropriate. In the
event of a termination by us, we will notify you of such termination.
You also have the right to terminate, in writing or orally, any
agreed-to restriction by sending such termination notice to Privacy
Officer, 4151 Holiday Street NW, Canton, OH 44718
- Access to Individual Health Information. You
have the right to inspect and copy your health information
maintained by this office. All requests for access must be made in
writing and signed by you or your representative. A fee of $2.84
per page for pages 1-10, .59 per page for pages 11-50, .24 per
page thereafter, will be charged if you request a copy of the
information. There will also be a charge for postage if you
request a mailed copy and, if requested, for preparation of a
summary of the requested information. You may obtain a request for
access form from Privacy Officer, 4151 Holiday Street NW, Canton,
OH 44718. In certain
circumstances, you may not be permitted access (e.g.,
psychotherapy notes, information compiled for legal action, or
information subject to prohibition by law).
Depending on the circumstances, you may request a review of
the decision to deny access.
- Amendments to Individual Health Information. You
have the right to request in writing that your health information
maintained by this office be amended or corrected. In certain
cases, we may deny your request for amendment. All amendment
requests must be in writing, signed by you or your representative,
and must state the reasons for the amendment. If we make an
amendment, we may also notify others who work with us and have
copies of the un-amended record if we believe that such
notification is necessary. You may obtain an amendment request
form from our Privacy Officer.
If we deny your request, you may submit a statement of
disagreement to us and we may prepare a rebuttal that will be
provided to you. These
materials may be distributed in future requests to review your
health information.
- Accounting for Disclosures of Individual Health Information. You
have the right to receive an accounting of certain disclosures
made by us of your health information after April 14, 2003.
Requests must be made in writing and signed by you or your
representative. Accounting request forms are available from our
Privacy Officer. The
first accounting in any 12-month period is free; you will be
charged a fee of $15.00 for each subsequent accounting you request
within the same twelve-month period.
The right to receive this information is subject to certain
exceptions, restrictions, and limitations.
COMPLAINTS:
If you believe your privacy rights have been violated, you may file a
complaint with the Privacy Officer by written mail.
You may also file a complaint with the Secretary of the U.S.
Department of Health and Human Services in Washington D.C. in writing.
There will be no retaliation for filing a complaint.
ADDITIONAL INFORMATION
If you have questions or need additional assistance
regarding this Notice, you may contact our Administrator at 4151
Holiday Street NW, Canton, OH 44718, (330) 492-2080.
PATIENT SIGNATURE:_______________________________Date________________________
AUTHORIZED REPRESENTATIVE (Title):
______________________________________
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Atrium OBGYN, Inc.
4151 Holiday St. NW
Canton, OH 44718
Ph: 330.492.8001
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