NOTICE OF PRIVACY PRACTICES
This Notice Describes How Health Information About You May Be Used And Disclosed And How You Can Get Access To This Information
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US!
OUR LEGAL DUTY- We are required by federal and state law to maintain the privacy of your health information. We are also required to give you the Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in the Notice while it is in effect. This Notice takes effect April 12, 2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of the Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice availab!e upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION – We use and disclose health information about you for treatment, payment, and healthcare operations:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our heaithcare ope8Dons. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioners and provider pei'formance, conduction training programs, reaccreditations, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or heaithcare operations; you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization you may revoke it in vlIiting at any time. Your revocation 'ViiI not affect any use or disclosures permitted by your authorization white it was in effect. Unless you give us a written authorization, we cannot use or disdose your heaith information for any reasor; except those described in the Notice.
To Your Family and Friends: We must disclose your health information to you as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (induding identifying or locating) a family member, your personal representative or another person responsible for your care, of you location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with a opportunity to object to such uses or disclosures, In the event of your incapacity of emergency circumstances, we wiii disciose heaith information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professionai judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies. x-rays, or other simiiar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communication without your written authorization.
Requirement by law: We may use or disclose your heaith information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose you health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal offidals health information required for lawful intelligence counterintelligence, and other national security activities. We may disclose to correctional institution or any enforcement officials pending lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voice mail message, postcards, or letters).
Access: You have the right, with limited exceptions, to look at or get copies of your PHI contained in a designated record set. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your PHI and may obtain a request form from us. We will charge you $0.25 for each page and postage if you want the copies mailed to your. If you request alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we can prepare a summary or an explanation of your PHI for a fee. Contact us using the information listed at the end of the Notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances since April 14, 2003 in which we or our business associates disclosed your PHI for purposes, other than treatment, payment, health care operations, or as authorized by you, and for certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your PHI we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communications: You have the right to request that we communicate with you about your PHI alternative means or to alternative locations. (You must make your request in writing.) Your request must spedfy the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing and must explain why the information should be amended.) We may deny your request under certain circumstances:·
Electronic Notice: If you receive this Notice on our Web site or by electronic mail, you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS- If you want more information about our privacy practices or have questions or concerned please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about accessing your PHI or in response to a request you made to amend or restrict the use or disdosure of your PHI or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.s. Dept. of Health and Human Services. We will provide you with the address to file your complaint with them upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Dept. of Health and Human Services.
Dr. Patrick Shafer 300 Clinic Drive Hopkinsville, KY 42240 (270) 889-9006