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NOTICE OF PRIVACY PRACTICES
Physician Room Service®
Your privacy is very important to us.
THIS NOTICE OF PRIVACY DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this Notice of Privacy, please contact our Privacy Officer. “Protected health information” (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices (NPP) describes how we may use and disclose your PHI to carry out treatment, payment or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. We are required to abide by the terms of this NPP, which may change at any time. Upon your request, we will provide you with any revised NPP. You may request by phone, postal mail or e-mail, that a revised copy be sent to you.
Uses and Disclosures of PHI: Your PHI may be used and disclosed by your physician, our staff, or others involved in providing health care services to you, to pay your health care bills, and to support the operation of your physician’s practice. Following are some examples of the types of uses and disclosures of your PHI that are permitted: Treatment: We may use and disclose your PHI as necessary to provide, coordinate, or manage your health care and any related services with other health care providers, such as specialists, to whom you are referred, or to a home health agency that provides care to you. Payment: Your PHI may be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the hospital admission. Health Care Operations: We may use or disclose, as needed, your PHI for business activities of your physician’s practice, such as quality assessment activities, employee review activities, training of medical students, licensing, or other business activities. We may share your PHI with third party “business associates” that may perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement with a business associate involves the use or disclosure of your PHI, we may have a written contract that contains terms that will protect the privacy of your PHI. We may use or disclose your PHI, as necessary, to contact you about appointment reminders, or to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object: Required By Law: We may use or disclose your PHI in compliance with the law, when required by law. You will be notified, if required by law, of any such uses or disclosures. Public Health: We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability. Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose 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 that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Abuse or Neglect: We may disclose your PHI to a public health authority, governmental entity, or agency authorized by law to receive reports of child abuse, neglect, or domestic violence, consistent with the requirements of applicable federal and state laws. Food and Drug Administration: We may disclose your PHI to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes, including (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation: 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 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. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye or tissue donation purposes. 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, or 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 PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, (3) to foreign military authority if you are a member of that foreign military services, or (4) 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. Workers’ Compensation: We may disclose your PHI as authorized to comply with workers’ compensation laws and other similar legally-established programs. Inmates: We may use or disclose your PHI if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
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 in writing at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization. Most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI, require express written authorization. Other uses and disclosures not described in the NPP will be made only with authorization.
Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or 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 agree or 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. Unless you object, we may disclose to a member of your family, 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 a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. We may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
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 request, obtain, and inspect copies of your PHI, including electronic copies (if maintained, available, and readily producible), for as long as we maintain the PHI. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. 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 laboratory results that are subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your PHI. You may request us not to use or disclose any part of your PHI to family members or friends who may be involved in your care. You may also request that PHI, with respect to health care that was paid for out of pocket in full, not be disclosed to a health plan. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. 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. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer. You have the right to opt out of receiving any fundraising communications for which we may or may not intend to contact you. You may have the right to have your physician amend your PHI. This means you may request an amendment of PHI about you in a designated record set for so long as we 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 any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this NPP. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures. The right to receive this information is subject to certain exceptions, restrictions and limitations. You have the right to be notified of any breach of unsecured PHI, as well as receive notifications of any breaches of unsecured PHI.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. You may contact our Privacy Officer, at (407)238-2000 or info@PhysicianRoomService.com for further information about the complaint process.
This form was originally based on an American Medical Association “Sample Notice of Privacy Practices” (which stated that, “Reproduction and use of this form by physicians and their staff is permitted”), accessed and downloaded from the American Medical Association’s website, recently revised to include updated Federal Regulations, and became effective on July 13, 2013.