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.
As part of our program, we maintain personal information about you and your health. State and federal law protects such information by limiting its uses and disclosures. “Protected health information” (“PHI”) is information about you, including demographic information, that may identify you or be used to identify you, and that relates to your past, present or future physical or mental health or condition, the provision of health care services, or the past, present or future payment for the provision of health care. The confidentiality of alcohol and drug abuse patient records is also specifically subject to additional restrictions under other state and federal law. We are required to comply with these additional restrictions
Your Rights Regarding Your PHI. The following are your rights regarding PHI that we maintain about you:
- Right of Access to Inspect and Copy. You have the right, which may be restricted only in certain limited circumstances, to inspect and copy your PHI that We maintain. We may charge a reasonable, cost-base fee for copies.
- Right to Amend. If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
- Right to an Accounting of Disclosures. You have the right to request a copy of the required accounting of disclosures that we make of your PHI.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosures your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
- Right to Request Confidential Communication. You have the right to request that we communicate with you in a certain way or at a certain location. We will accommodate reasonable requests and will not ask why you are making the request.
- Right to a Copy of this Notice. You have the right to a paper copy of this notice.
- Right of Complaint. You have the right to file a complaint in writing with us or with the Secretary of Health and Human Services if you believe we have violated your privacy rights. We will not retaliate against you for filing a complaint.
Our Uses and Disclosures of PHI for Treatment, Payment, and Healthcare Operations.
Treatment. We may use your PHI for the purpose of providing you with health care treatment. To coordinate and manage your care, we may disclose your PHI to others of your current providers, and to the extent you have not raised an objection in writing, to your prior providers. We may also disclose your PHI to other health care providers who become involved in your care.
Telehealth/Telemedicine. Healthcare treatment and/or treatment programming may include telehealth. Your rights regarding PHI and the laws and regulations for use and disclosure apply to telemedicine as they would to traditional in person treatment.
Payment. We may use your PHI in connection with billing statements we send you and our system for tracking charges and credits to your account. In addition, but with your authorization, we may disclose your PHI to third party payers to obtain information concerning benefit eligibility, coverage, and remaining availability, as well as to submit claims for payment and for medical necessity and utilization reviews.
Health Care Operations. We may use and disclose your PHI for the health care operations of our program in support of the functions of treatment and payment. Such disclosures would be to a Qualified Organization only or to a Business Associate/QSO to provide services to the program and its patients for data processing, bill collecting, dosage preparation, laboratory analysis, or legal, medical, accounting, or other professional services, or services to prevent or treat child abuse or neglect, including training on nutrition and child care and individual and group therapy.
Uses and Disclosures That Do Not Require Your Authorization or Opportunity to Object
Required by Law. We may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. For example, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Audit and Evaluation. We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies, and organizations that provide financial assistance to the program (such as third-party payers) and peer review organizations performing utilization and quality control. If we disclose PHI to a health oversight agency, we will have an agreement in place that requires the agency to safeguard the privacy of your PHI.
Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only.
Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.
Research. We may disclose your PHI for use a research project that an institutional review board has determined to be of sufficient importance to outweigh the privacy intrusion, to be impracticable without PHI, to have specified safeguards against further disclosure in reports or otherwise, and, among, other provisions, to require destruction or de-identification of your PHI.
Criminal Activity on Program Premises/ Against Program Personnel. We may disclose your PHI to law enforcement officials if you have committed a crime on program premises or against program personnel or you have made a threat to commit such crimes. Such disclosure is limited to circumstances of the incident, including name, address, status as a patient, and last known whereabouts.
Qualified Service Organization. We may disclose your PHI to a Qualified Service Organization to provide certain services to the program and its patients, such as data processing, bill collecting, dosage preparation, laboratory analyses, or legal, medical, accounting or other professional services, or services to prevent or treat child abuse or neglect, including training on nutrition and child care and individual and group therapy. If a QSO has more than incidental access to PHI, and/or the functions or services relate to payment, then a Business Associate Agreement will be utilized; otherwise only a Qualified Organization Agreement will be used. In the case the service is from a health care provider performing services to treat you, a Business Associate Agreement will not be utilized because you will have a direct patient-provider relationships.
Court Order. We may disclose your PHI if a court of competent jurisdiction issues and appropriate order.
Uses and Disclosures of PHI With Your Written Authorization.
We will make other uses and disclosures of your PHI only with your written authorization. You may revoke this authorization in writing at any time, unless we have taken a substantial action in reliance on the authorization such as providing you with health care services for which we must submit subsequent claim(s) for payment.
This Notice of Privacy Practices informs you how We may use and disclose your protected health information (“PHI”) and your rights regarding your PHI. We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to your PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI we maintain at that time. We will make available a revised Notice of Privacy Practices by providing you a copy upon your request, or providing a copy to you at your next appointment.
If you have any questions about this Notice of Privacy Practices,
Please contact our Privacy Officer:
Mark Loes or Designee
Sundown M Ranch
P.O. Box 217
Selah WA 98942
or e-mail email@example.com.
If you believe we have violated your privacy rights you may file a complaint in writing to us, in care of our Privacy Officer. We will not retaliate against you for filing a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services.
The effective date of this Notice is April 14, 2003