NOTICE OF PRIVACY PRACTICES

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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. Effective: April 14, 2003

We are dedicated to maintaining the privacy of your health information. In conducting business, we will create records regarding you and the treatment and services we will provide.

These records are the property of our agency. However, we are required by law:

• To maintain the confidentiality of your health information.
• To provide you with the notice of our legal duties and privacy practices concerning your health information.
• To follow the terms of our notice of privacy practices in effect at the time.

This notice provides you with the following information:

• How we may use and disclose your health information.
• Your privacy rights and your health information.
• Our obligations concerning the use and disclosure of your health information.

How We May Use and Disclose Your Health Information

The following categories describe the different ways that we may use and disclose your health information. Not every possible use or disclosure is specifically mentioned. However, the different ways we are permitted to use or disclose your health information fall within one of these categories.

For Treatment

We will use medical information about you to provide you with medical treatment and services. We will disclose medical information to doctors, nurses, case managers/support coordinators and other office personnel who are involved in providing you with treatment.

For Payment

We may use and disclose medical information about you so that treatment and services received from our Agency may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about treatment you received so your health plan will pay us or reimburse you for treatment. We may also tell your health plan about a treatment you are going to receive, to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations

We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to maintain our office and make sure that all of our consumers receive quality care. Examples: Our organization may use your health information to evaluate the quality of care you received, or to conduct cost-management and business planning activities for our organization. Further, we may disclose your information to doctors, nurses, students, and other personnel for review and learning purposes. We may remove identifying information from the medical information so others may use it to study health care and health care delivery without learning the identity of the specific consumers.

For Appointment Reminders or Treatment Alternatives

Our organization may use and disclose your health information to remind you that you have an appointment, or to provide information about treatment alternatives or other health-related benefits and services that may be of interest.

To Business Associates

We may share your health information with “business associates” that perform services for us (such as attorneys) through contracts that we have with them. These contracts identify terms that safeguard your health information.

To Others Involved in Your Healthcare

Unless you object, we may disclose to a family member, a relative, a close friend, or any other person that you identify, your health information that directly relates to that person’s involvement in your care or payment related to your care. If you are not able to agree or object to a disclosure, we will use our professional judgment regarding such disclosure.

Use and/or Disclosures to the Recipient

If a valid authorization is provided, we may use and disclose your health information to you, as a recipient of our services, your guardian with authority to authorize such use or disclosure, the parent with legal custody of a minor recipient, or the court-appointed personal representative or executor of the estate of a deceased recipient, unless in the written judgment of our agency, the disclosure would be detrimental to the recipient or others.

As Required by Law

We will disclose medical information about you when required by federal, state or local law. For example, disclosure may be required by Workers’ Compensation statutes or various public health statutes in connection with required reporting of certain diseases, abuse and neglect, domestic violence, adverse drug reaction, etc.

Health Oversight Activities

We may disclose medical information to a governmental or other oversight agency for activities authorized by law. For example, disclosures of your medical information may be made in connection with audits, investigations, inspections, and licensure renewals.

Lawsuits and Similar Proceedings

If you are involved in a lawsuit or dispute, we may use your medical information to defend the office or to respond to a court order. We also may disclose your health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

Law Enforcement

We may release medical information about you if required by law when asked to do so by a law enforcement official.

Coroners, Medical Examiners, and Funeral Directors

We may release medical information to a coroner or medical examiner to identify a deceased person or determine the cause of death.

Research

Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received a medication to those who received another medication for the same condition.

To Avert a Serious Threat to Health of Safety

We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would be to someone able to help prevent the threat.

For Specialized Government Functions

Our organization may disclose your health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. In addition, our organization may disclose your health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your health information to federal officials to protect the President, other officials, or foreign heads of state, or to conduct investigations.

Our organization may disclose your health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (1) for the institution to provide health care services to you, (2) for the safety and security of the institution, and/or (3) to protect your health and safety or the health and safety of other individuals.

Your Rights Regarding Your Health Information

Your have the following rights regarding the health information that we maintain about you.

Right to Inspect and Copy

You have the right to inspect and copy your medical information with the exception of any psychotherapy notes. To inspect and copy your medical information, you must submit your request in writing to the Privacy Officer.

If you request a copy of the information, we may charge for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed. For information regarding a review, contact your Privacy Officer.

Right to Amend

If you feel medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by this office.

To request an amendment, your request must be made in writing and submitted to the Privacy Officer. We may deny your request if you ask us to amend information that:

• Was not created by us;
• Is not part of the medical information kept by this office;
• Is not part of the information that you would be permitted to inspect and copy;
• Is accurate and complete.

Right to Accounting of Disclosures

You have the right to request an “accounting of disclosures.” This is a list of the disclosures this office has made of your medical information.

To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003.

Right to Request Restrictions

You have the right to request a restriction or limitation on the use or disclosure we make of your medical information.

We are not required to agree to your request for a restriction. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request a restriction, you must make your request in writing to the Privacy Officer.

Confidential Communications

You have the right to request we communicate with you only in a certain manner. For example, you can ask that we contact you only at work or by mail.

To request confidential communications, you must make your request in writing to the Privacy Officer. We will accommodate all reasonable requests.

Revisions to this Notice

We reserve the right to revise this notice. Any revised notice will be effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of any revised notice. Any revised notice will contain on the first page, in the bottom right-hand corner, the effective date. Any revision or amendment to this notice will be effective for all of the information we already have about you, as well as any of your health information we may receive, create, or maintain in the future.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with this office or with the Secretary of the Department of Health and Human Services. To file a complaint with this office, contact your Privacy Officer. All complaints must be submitted in writing or followed up in writing.

You will NOT be penalized in any way for filing a complaint.

Other Uses of Medical Information

Other uses and disclosures of your medical information not covered by this Notice of Privacy Practices will be made only with your written authorization. If you provide us such an authorization in writing to use or disclose medical information about you, you may revoke that authorization in writing at any time. If you revoke any authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.

If you have any questions about our Privacy Practices, ask your Privacy Officer.

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