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Effective Date: 4/15/03
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.
WHO WILL FOLLOW THIS NOTICE.
This notice describes our practice's privacy practices and
that of:
- Any physician or health care professional authorized to enter information
into your medical chart.
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All departments and units of the practice.
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All employees, staff and other office personnel.
- All
these individuals, sites and locations follow the terms of this
notice. In addition, these individuals, sites and locations may
share medical information with each other or with third party
medical specialists for treatment, payment or office operations
purposes described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We are required by law to:
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make sure that medical information that identifies you is kept private;
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give you this notice of our legal duties and privacy practices with
respect to medical information about you; and
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follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE
MEDICAL INFORMATION ABOUT YOU.
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For Treatment. We may use medical information about you to provide you
with medical treatment or services. We may disclose medical information
about you to the practice's office personnel who are involved
in taking care of you at the office or elsewhere. We also may
disclose medical information about you to people outside our office
who may be involved in your care after you leave the office, such
as family members or others we use to provide services that are
part of your care provided you have consented to such disclosure.
These entities include third party physicians,
hospitals, nursing homes, pharmacies or clinical labs with whom
the office consults or makes referrals.
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For
Payment. We may use and disclose medical
information about you so that the treatment and services you receive
at Lake Health Care Center 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
medical procedures you received at the office so your health plan
will pay us or reimburse you for the services. 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.
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For
Health Care Operations. We may use and disclose medical
information about you for medical office operations. These uses
and disclosures are necessary to run the medical office and make
sure that all of our patients receive quality care. For example,
we may use medical information to review our treatment and services
and to evaluate the performance of our staff in caring for you.
We may also combine medical information about many medical office
patients to decide what additional services the office should
offer, what services are not needed, and whether certain new treatments
are effective. We may also disclose information to necessary
office personnel for review and learning purposes.
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Appointment
Reminders. We may use and disclose medical
information to contact you as a reminder that you have an appointment
for treatment or medical care at the office.
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Treatment
Alternatives. We may use and disclose medical
information to tell you about or recommend possible treatment
options or alternatives that may be of interest to you.
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Health-Related
Benefits and Services. We may use and disclose medical information to tell you about
health-related benefits or services that may be of interest to
you.
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Individuals
Involved in Your Care or Payment for Your Care.
We may release medical information about you to a friend or family
member who is involved in your medical care provided you have
consented to such disclosure. We may also give information to
someone who helps pay for your care. In addition, we may disclose
medical information about you to an entity assisting in a disaster
relief effort so that your family can be notified about your condition,
status and location.
- As
Required By Law. We will disclose medical
information about you when required to do so by federal, state
or local law.
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To
Avert a Serious Threat to Health or 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 only be to someone able to help prevent the threat.
SPECIAL SITUATIONS
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Health
Oversight Activities. We may disclose medical information
to a health oversight agency for activities authorized by law.
These oversight activities include, for example, audits, investigations,
inspections, and licensure. These activities are necessary for
the government to monitor the health care system, government programs,
and compliance with civil rights laws.
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Lawsuits
and Disputes. If you are involved in a
lawsuit or a dispute, we may disclose medical information about
you in response to a court or administrative order. We may also
disclose medical information about you in response to a subpoena,
discovery request, or other lawful process by someone else involved
in the dispute, but only if efforts have been made to tell you
about the request or to obtain an order protecting the information
requested.
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Law
Enforcement. We may release medical information
if asked to do so by a law enforcement official:
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In response to a court order, subpoena, warrant, summons or similar
process;
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To identify or locate a suspect, fugitive, material witness, or missing
person;
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About the victim of a crime if, under certain limited circumstances,
we are unable to obtain the person's agreement;
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About a death we believe may be the result of criminal conduct;
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About criminal conduct at the medical office; and
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In emergency circumstances to report a crime; the location of the
crime or victims; or the identity, description or location of
the person who committed the crime.
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Coroners,
Medical Examiners and Funeral Directors.
We may release medical information to a coroner or medical examiner.
This may be necessary, for example, to identify a deceased person
or determine the cause of death. We may also release medical
information about patients of the office to funeral directors
as necessary to carry out their duties.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights
regarding medical information we maintain about you:
- Right
to Inspect and Copy.
You have the right to inspect and copy medical information that
may be used to make decisions about your care. To inspect and
copy medical information that may be used to make decisions about
you, you must submit your request in writing to Lorri Hartley
or the privacy officer. If you request a copy of the information,
we may charge a fee for the costs of copying, mailing or other
supplies associated with your request. We
may deny your request to inspect and copy in certain very limited
circumstances.
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Right
to Amend. If you feel that 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 or for
the medical office.
To request an amendment, your
request must be made in writing and submitted to Lorri Hartley
or the privacy officer. In addition, you must provide a reason
that supports your request.
We may deny your request for
an amendment if it is not in writing or does not include a reason
to support the request. In addition, we may deny your request
if you ask us to amend information that:
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Was not created by us, unless the person or entity that created the
information is no longer available to make the amendment;
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Is not part of the medical information kept by or for the medical
office;
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Is not part of the information which you would be permitted to inspect
and copy; or
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Is accurate and complete.
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Right
to an Accounting of Disclosures. You have the right to request an "accounting
of disclosures." This is a list of the disclosures we made
of medical information about you.
To request this list or accounting
of disclosures, you must submit your request in writing to Lorri
Hartley or the privacy office. Your request must state a time
period which may not be longer than six years and may not include
dates before 4/14/03. Your request should indicate in what form
you want the list (for example, on paper, electronically). The
first list you request within a 12 month period will be free.
For additional lists, we may charge you for the costs of providing
the list. We will notify you of the cost involved and you may
choose to withdraw or modify your request at that time before
any costs are incurred.
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Right
to Request Restrictions. You have the right to request
a restriction or limitation on the medical information we use
or disclose about you for treatment, payment or health care operations.
You also have the right to request a limit on the medical information
we disclose about you to someone who is involved in your care
or the payment for your care, like a family member or friend.
For example, you could ask that we not use or disclose information
about a surgery you had.
We are not required
to agree to your request. If we do agree, we will comply with your request unless the information
is needed to provide you emergency treatment.
To request restrictions, you
must make your request in writing to Lorri Hartley or the privacy
officer. In your request, you must tell us (1) what information
you want to limit; (2) whether you want to limit our use, disclosure
or both; and (3) to whom you want the limits to apply, for example,
disclosures to your spouse.
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Right
to Request Confidential Communications. You have the right to request that we communicate
with you about medical matters in a certain way or at a certain
location. For example, you can ask that we only contact you at
work or by mail.
To request confidential communications,
you must make your request in writing to Lorri Hartley or the
privacy officer. We will not ask you the reason for your request.
We will accommodate all reasonable requests. Your request must
specify how or where you wish to be contacted.
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Right
to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask
us to give you a copy of this notice at any time. Even if you
have agreed to receive this notice electronically, you are still
entitled to a paper copy of this notice.
To obtain a paper copy of this
notice, please request one at the front desk.
CHANGES TO THIS NOTICE
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We reserve the right to change this notice. We reserve the right
to make the revised or changed notice 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 the current notice in the
office. The notice will contain on the first page, in the top
right-hand corner, the effective date. In addition, each time
you register we will offer you a copy of the current notice in
effect.
COMPLAINTS
If you believe your privacy
rights have been violated, you may file a complaint with the office
or with the Secretary of the Department of Health and Human Services.
To file a complaint with our practice, contact Lorri Hartley
or the privacy officer at (352)357-8615. All complaints must
be submitted in writing.
You will not be penalized
or retaliated against for filing a complaint.
OTHER USES OF MEDICAL INFORMATION.
Other uses and disclosures of
medical information not covered by this notice or the laws that
apply to us will be made only with your written permission. If
you provide us permission to use or disclose medical information
about you, you may revoke that permission, in writing, at any
time. If you revoke your permission, we will no longer use or
disclose medical information about you for the reasons covered
by your written authorization. You
understand that we are unable to take back any disclosures we
have already made with your permission, and that we are required
to retain our records of the care that we provided to you.
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