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NOTICE OF PRIVACY PRACTICES

Company Name

101 FRANKLIN STREET, WESTERLY, NY 00001

Tel: 212 555-1345     FAX: 212 555-1346

OFFICE CONTACT PERSON: Office Manager

 

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Understanding Your Health Record/Information

Each time you visit a physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

bulletbasis for planning your care and treatment
bulletmeans of communication among the many health professionals who contribute to your care
bulletlegal document describing the care you received
bulletmeans by which you or a third party payer can verify that services billed were actually provided
bulleta tool in educating heath professionals;
bulleta source of data for medical research;
bulleta source of information for public health officials charged with improving the health of the nation;
bulleta source of data for facility planning and marketing and
bulleta tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to:

bulletensure its accuracy
bulletbetter understand who, what, when, where and why others may access your health information
bulletmake more informed decisions when authorizing disclosure to others.

Your Health Information Rights:

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

bulletrequest a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522
bulletobtain a paper copy of the notice of information practices upon request
bulletinspect and copy your health record as provided for in 45 CFR 164.524
bulletamend your health record as provided in 45 CFR 164.528
bulletobtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
bulletrequest communications of your health information by alternative means or at alternative locations
bulletrevoke your authorization to use or disclose health information except to the extent that action has already been taken.

 

Our Responsibilities:

This organization is required to:

bulletmaintain the privacy of your health information
bulletprovide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
bulletabide by the terms of this notice
bulletnotify you if we are unable to agree to a requested restriction
bulletaccommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you've supplied us.

We will not use or disclose your health information without your authorization, except as described in this notice.

For More Information or to Report a Problem

If have questions and would like additional information, you may contact the Director of Health Information Management at (444) 111-1111.

If you believe your privacy rights have been violated, you can file a complaint with the Director of Health Information Management or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

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 healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his expectations of the members of your healthcare team. Members of your healthcare 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 your physician or a subsequent healthcare provider with copies of various reports that should assist him/her in treating you once you're discharged from this hospital.

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.

We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Other Uses or Disclosures

Business Associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the Emergency Department and Radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do and bill you or your third party payer for services rendered. So that your health information is protected, however, we require the business associate to appropriately safeguard your information.

Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation to other people who ask for you by name.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

Communication with Family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.

Research: We may disclose information to researchers when their research has been approved by an Institutional Review Board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.

Fund Raising: We may contact you as part of a fund-raising effort.

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

Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof, health information necessary for your health, and the health and safety of other individuals.

Law Enforcement: We may disclose health information for law enforcement purposes as required by law, or in response to a valid subpoena.

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

ACKNOWLEDGMENT OF RECEIPT OF

OUR NOTICE OF PRIVACY PRACTICES

 

By signing below, I acknowledge that I have been provided with a copy of the Company Name Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by Company Name and how I may obtain access to and control this information.

 

X_____________________________________________________.

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE

 

 

X_____________________________________________________.

       PRINT NAME OF PATIENT OR PERSONAL REPRESENTATIVE

 

X_____________________________________________________.

             DATE

  

_____________________________________________________.

DESCRIPTION OF PERSONAL REPRESENTATIVES AUTHORITY

 

1.       Please list who you want to have access to your pertinent medical information?

(i.e.: family member, spouse, significant other)

 

 

2.       May we leave message on answering machine?  YES      NO

 

3.       Preferred method of contact?

Home #_____________________Cell #_____________________Work #________________________.

THIS SECTION WILL BE COMPLETED IF THE WRITTEN ACKNOWLEDGEMENT NOT OBTAINED

We have made a good faith effort to obtain an individual's acknowledgement, but the acknowledgement was not obtained for the following reason(s):

 

___The individual refuses to sign or otherwise fails to provide an acknowledgement

 

___The individual was mailed a copy of the Notice and did not mail back his or her receipt of acknowledgement.

 

___ Other_________________________________________________________________________________.

 

Completed by_______________________________________________________________________________.

 

Date____________________________________.