FORM-9:  HIPAA Notice of Privacy Practices (long version)

This notice describes how your medical information may be used and disclosed and how you can get access to this information. Please read it carefully. We are here to assist you with any questions you may have.

WE HAVE A LEGAL DUTY TO PROTECT HEALTH INFORMATION ABOUT YOU.

We are required by law to protect the privacy of health information about you, which we call “protected health information,” or “PHI” for short.  We must give you notice of our legal duties and privacy practices concerning PHI:

We must protect PHI that we have created or received about your past, present, or future health condition, health care we provide to you, or payment for your health care. 

• We must notify you about how we protect PHI about you. 
• We must explain how, when and why we use and/or disclose PHI about you. 
• We may only use and/or disclose PHI as we have described in this Notice. 

We are required to follow the procedures in this Notice.  We reserve the right to change the terms of this Notice (and the terms under which we maintain PHI) and to make new notice provisions effective for all PHI that we maintain by:

• Posting the revised notice in our offices;
• Making copies of the revised notice available upon request (either at our offices or through the contact person listed in this Notice); and
• Posting the revised notice on our website.

WE MAY USE AND DISCLOSE PHI ABOUT YOU WITHOUT YOUR AUTHORIZATION IN THE FOLLOWING CIRCUMSTANCES. 

1. We may use and disclose PHI about you to provide health care treatment to you.  

We may use and disclose PHI about you to provide, coordinate or manage your health care and related services.  This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others.  In addition, we may use and disclose PHI about you when referring you to another health care provider.  For example, if you are referred to another doctor, your doctor may provide that doctor information on whether you are allergic to any medications.  Similarly, your doctor may share PHI about you with a pharmacy when calling in a prescription.  

2. We may use and disclose PHI about you to obtain payment for services.  
Generally, we may use and give your medical information to others to collect payment for the treatment and services provided to you.  For example, we may share portions of your medical information with the following:

• Collection departments or agencies;
• Hospital departments that review the care you received to check that it and the costs associated with it were appropriate for your illness or injury; and
• Consumer reporting agencies (e.g., credit bureaus).

3. We may use and disclose your PHI for health care operations.  

We may use and disclose PHI in performing business activities, which we call “health care operations”.  These “health care operations” allow us to improve the quality of care we provide and reduce health care costs.  Examples of the way we may use or disclose PHI about you for “health care operations” include the following:

• Reviewing and improving the quality, efficiency and cost of care that we provide to you and our other patients.  For example, we may use PHI about you to develop ways to assist our health care providers and staff in deciding what medical treatment should be provided to others. 
• Improving health care and lowering costs for groups of people who have similar health problems and to help manage and coordinate the care for these groups of people.  We may use PHI to identify groups of people with similar health problems to give them information, for instance, about treatment alternatives, classes, or new procedures. 
• Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care of you.
• Providing training programs for students, trainees, health care providers or non-health care professionals (for example, physician affiliates and their office staff) to help them practice or improve their skills. 
• Cooperating with outside organizations that assess the quality of the care we and others provide.  These organizations might include government agencies or accrediting bodies.
• Cooperating with outside organizations that evaluate, certify or license health care providers, staff or facilities in a particular field or specialty.  For example, we may use or disclose PHI so that one of our nurses may become certified as having expertise in a specific field of nursing.
• Assisting various people who review our activities.  For example, PHI may be seen by doctors reviewing the services provided to you, and by accountants, lawyers, and others who assist us in complying with applicable laws. 
• Planning for our organization’s future operations, and fundraising for the benefit of our organization.
• Conducting business management and general administrative activities related to our organization and the services it provides, including providing info.
• Resolving grievances within our organization.
• Reviewing activities and using or disclosing PHI in the event that we sell our business, property or give control of our business or property to someone else.
• Complying with this Notice and with applicable laws.

4. We may use and disclose PHI under other circumstances without your authorization.

• We may use and/or disclose PHI about you for a number of circumstances in which you do not have to consent, give authorization or otherwise have an opportunity to agree or object.  Those circumstances include:
• When the use and/or disclosure is required by law.  For example, when a disclosure is required by federal, state or local law or other judicial or administrative proceeding.
• When the use and/or disclosure is necessary for public health activities.  For example, we may disclose PHI about you if you have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
• When the disclosure relates to victims of abuse, neglect or domestic violence.
• When the use and/or disclosure is for health oversight activities.  For example, we may disclose PHI about you to a state or federal health oversight agency which is authorized by law to oversee our operations.
• When the disclosure is for judicial and administrative proceedings.  For example, we may disclose PHI about you in response to an order of a court or administrative tribunal.
• When the disclosure is for law enforcement purposes.  For example, we may disclose PHI about you in order to comply with laws that require the reporting of certain types of wounds or other physical injuries.
• When the use and/or disclosure relates to decedents.  For example, we may disclose PHI about you to a coroner or medical examiner for the purposes of identifying you should you die.
• When the use and/or disclosure relates to cadaveric organ, eye or tissue donation purposes.
• When the use and/or disclosure relates to medical research.  Under certain circumstances, we may disclose PHI about you for medical research.
• When the use and/or disclosure is to avert a serious threat to health or safety.  For example, we may disclose PHI about you to prevent or lessen a serious and eminent threat to the health or safety of a person or the public.
• When the use and/or disclosure relates to specialized government functions.  For example, we may disclose PHI about you if it relates to military and veterans’ activities, national security and intelligence activities, protective services for the President, and medical suitability or determinations of the Department of State.

5. You can object to certain uses and disclosures.
Unless you object, we may use or disclose PHI about you in the following circumstances:

• We may share with a family member, relative, friend or other person identified by you, PHI directly related to that person’s involvement in your care or payment for your care.  We may share with a family member, personal representative or other person responsible for your care PHI necessary to notify such individuals of your location, general condition or death. 
• We may share with a public or private agency (for example, American Red Cross) PHI about you for disaster relief purposes.  Even if you object, we may still share the PHI about you, if necessary for the emergency circumstances.
  

If you would like to object to our use or disclosure of PHI about you in the above circumstances, please call our contact person listed on the cover page of this Notice.

6. We may contact you to provide appointment reminders.
We may use and/or disclose PHI to contact you to provide a reminder to you about an appointment you have for treatment or medical care.

7. We may contact you with information about treatment, services, products or health care providers.
We may use and/or disclose PHI to manage or coordinate your healthcare.  This may include telling you about treatments, services, products and/or other healthcare providers.  For example, if you are diagnosed with diabetes, we may tell you about nutritional and other counseling services that may be of interest to you. 

ANY OTHER USE OR DISCLOSURE OF PHI ABOUT YOU REQUIRES YOUR WRITTEN AUTHORIZATION.

Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you.  If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing.  If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures which were being processed before we received your cancellation.

YOU HAVE SEVERAL RIGHTS REGARDING PHI ABOUT YOU.

1. You have the right to request restrictions on uses and disclosures of PHI about you.
You have the right to request that we restrict the use and disclosure of PHI about you.  We are not required to agree to your requested restrictions.  However, even if we agree to your request, in certain situations your restrictions may not be followed.  These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in the previous section of this Notice.  You may request a restriction by submitting your request in writing.  

2. You have the right to request different ways to communicate with you. 
You have the right to request how and where we contact you about PHI.  For example, you may request that we contact you at your work address or phone number or by email.  Your request must be in writing.  We must accommodate reasonable requests, but, when appropriate, may condition that accommodation on your providing us with information regarding how payment, if any, will be handled and your specification of an alternative address or other method of contact.  

3. You have the right to see and copy PHI about you.
You have the right to request to see and receive a copy of PHI contained in clinical, billing and other records used to make decisions about you.  Your request must be in writing.  We may charge you related fees.  Instead of providing you with a full copy of the PHI, we may give you a summary or explanation of the PHI about you, if you agree in advance to the form and cost of the summary or explanation.  There are certain situations in which we are not required to comply with your request.  Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any rights you may have to request a review of our denial.  

4. You have the right to request amendment of PHI about you.
You have the right to request that we make amendments to clinical, billing and other records used to make decisions about you.  Your request must be in writing and must explain your reason(s) for the amendment.  We may deny your request if: 1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record); 2) the information is not part of the records used to make decisions about you; 3) we believe the information is correct and complete; or 4) you would not have the right to see and copy the record as described in paragraph 3 above.  We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial.  If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received PHI about you and who need the amendment.  

5. You have the right to a listing of disclosures we have made.
If you ask our contact person in writing, you have the right to receive a written list of certain of our disclosures of PHI about you.  You may ask for disclosures made up to six (6) years before your request.  We are not required to include disclosures:

• For your treatment
• For billing and collection of payment for your treatment
• For our health care operations
• Requested by you, that you authorized, or which are made to individuals involved in your care, and
• Allowed by law (for examples, please SEE the section above).
• The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure.  If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee.  
  

6. You have the right to a copy of this Notice.
You have the right to request a paper copy of this Notice at any time.  We will provide a copy of this Notice no later than the date you first receive service from us (except for emergency services, and then we will provide the Notice to you as soon as possible).

YOU MAY FILE A COMPLAINT ABOUT THE PRIVACY PRACTICES.

If you think your privacy rights have been violated by us, or you want to complain to us about our privacy practices, you can contact us using the telephone number listed on the first page of this Notice, or you can send a written complaint to the United States Secretary of the Department of Health and Human Services.  If you file a complaint, we will not take any action against you or change our treatment of you in any way.

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