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Notice of Privacy - April 2003

This office is required by a federal regulation, known as the HIPAA Privacy Rule, to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices.  This office will not use or disclose your health information except as described in this Notice.

The office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and healthcare operations.  Protected health information is the information we create and obtain in providing our services to you.  The health information about you is documented in a medical record and on a computer.  Such information may include documenting symptoms, medical history, examination and test results, diagnosis, treatment and applying for future care or treatment.  It also includes billing documents for those services.  These examples are not meant to be exhaustive but to describe the types of uses and disclosures that may be made by our office.

 Examples of Disclosures for Treatment, Payment and Health Operations:

We will use your health information for treatment.

For example:  Information obtained by a nurse, physician, or other member of your health care team will be recorded in you record and used to determine the course of treatment that should work best for you.  Your physician will document in your record his or her expectations of the members of your health care team.  Members of your health care team will then record the actions they took and their observations.  In that way, the physician will know how you are responding to treatment.

We will also provide other physicians or a subsequent health care provider with copies of various reports that should assist him or her in treating you and obtain input.

We will use your health information for payment.

For example:  A bill may be sent to you or a third party payer.  The information on or accompanying the bill may include information that identifies you as well as your diagnosis, procedures, and supplies used.  This may include making a determination of eligibility or coverage for insurance benefits.

We will use your health information for regular health operations.

For example:  We obtain services from our insurers or other business associates (an individual or entity under contract with us to perform or assist us in a function or activity that necessitates the use or disclosure of health information ) such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, surgical assists, anesthesiologists, credentialing, medical transcription, medical review, legal services and insurance.  We will share health information about you with our insurers or other business associates to protect confidentiality of your health information.  Other examples:  1).  We may disclose PHI by using a sign-in sheet at the front desk; we will call you by name in the waiting room when your provider/physician is ready to see you.  2).  We may use or disclose PHI, as necessary, to contact you via telephone/mail to remind you of your appointment, results of laboratory analysis performed on your behalf, and to notify you of potential treatment options or alternatives.

Uses and Disclosures of Protected Health Information Based upon Your written Authorization

Other uses and disclosures of your PHI will be made only with your written authorization unless otherwise permitted or required by law as described below.  You may revoke this authorization at any time except to the extent that your physician or the physician’s practice has taken action in reliance on the use of disclosure indicated in the authorization.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Authorization or Opportunity to Object

We may use and disclose your PHI in the following instances:  You have the opportunity to agree or object to the use or disclosure of all or part of your PHI.  If you are not present or able to object to the use or disclosure of the PHI, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.  In this case, only the PHI that is relevant to your health will be disclosed.

Others Involved in Your Healthcare:

Unless you object, we may disclose to a family member, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care.  If you are unable to agree or object to such disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

Other Disclosures and Uses We Can Make Without Your Written Authorization or Opportunity to Object

Public Health:  We may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability, to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.

Abuse, Neglect and Domestic Violence:  We may disclose your health information to public authorities as allowed by law to report abuse, neglect, or domestic violence.

Food and Drug Administration (FDA):  We may disclose to the FDA your health information relating to adverse events with respect to food, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.

Law Enforcement:  We may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes.

Coroners, Funeral Directors and Organ Donations:  We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties as authorized by law.  We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.

Research:  We may disclose your PHI to researchers to determine if you meet the criteria to participate in a clinical research study and may contact you about participation.

Criminal Activity:  Consistent with applicable federal and state laws, we may disclose your PHI, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security:  When the appropriate conditions apply, we may use or disclose to PHI of individuals who are Armed Forces personnel.  We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities including for the provision of protective services to the President or others legally authorized.

Worker’s Compensation:  If you are seeking compensation through Worker’s Compensation, we may disclose your health information to the extent necessary to comply with laws relating to Worker’s Compensation.

Health Oversight:  We may disclose your health information to appropriate health oversight agencies or for health oversight activities such as audits, investigations, and inspections.

Schools, School Nurses or Camps: We may disclose your health information to school officials/nurses and /or camps to assist them in identifying appropriate care and activities. 

Inmates:  We may use or disclose your PHI if you are an inmate of a correctional facility and your physician created and received your protected health information in the course of providing care to you.

Required Uses and Disclosures:  Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with the requirements of HIPAA of 1996.

Your Rights

Following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information.   This means you may inspect and obtain a copy of PHI about you that is contained in a designated record set for as long as we maintain the PHI.  A “designated record set” contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.

Under federal law, however, you may not inspect or copy the following records:  Psychotherapy notes; information compiled in reasonable anticipation of or use in a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to PHI.  Depending on the circumstances, a decision to deny access may be reviewed.  In some circumstances, you may have the right to have this decision reviewed.

You have the right to request a restriction of your protected health information.  This means you have the right to request a restriction in our use or disclosure of your PHI for treatment, payment, or healthcare operations.  We are not required to agree to your request and in some cases where the requested restrictions limit our ability to provide quality healthcare, will recommend that you seek medical treatment with another healthcare provider or facility.  You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.  In order to request a restriction on our use or disclosure of your PHI, you must make your request in writing to:  Office Manager.  Your request must describe in a clear and concise fashion:

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.  We will accommodate reasonable requests.

Request Amendments.  This means you may request an amendment of PHI about you in a designated record set for as long as we can maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal.  Please contact the office manager to investigate your questions about amending your medical record.

Accounting  Disclosures.  This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you, family members or friends involved in your care or for notification purposes.  You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003.  You may request a shorter timeframe.  The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to receive a copy of this notice from us upon request.

For more information or to report a problem.

If you have questions and would like additional information, you may contact the practice’s Privacy Officer, at 520-323-3099.

If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer or with the Office for Civil Rights, U. S. Department of Health and Human Services.  There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights.  The address for the OCR is listed below:

Office for Civil Rights
U. S. Department of Health and Human Services
200 Independence Avenue, S. W.
Room 509F, HHH Building
Washington, D.C. 20201

Now please go to the Patient Registration Form that you can print out, sign, and bring to your appointment.  We must have this form signed and on file before your child can be seen for an appointment.

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