Deceased Persons
We may disclose your health information to funeral directors, medical examiners,
or coroners consistent with applicable law to allow them to carry out their
duties. This may be necessary, for example, to identify a deceased person
or determine the cause of death. We may also release health information
about patients to funeral directors as necessary for them to carry out
their duties.
Organ Procurement Organizations
Consistent with applicable law, we may disclose your health information to
organ procurement organizations or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose of tissue donation
and transplant.
Appointment Reminders, Marketing and Treatment Alternatives
We may contact you to provide you with appointment reminders, with information
about treatment alternatives, or with information about other health-related
benefits and services that may be of interest to you. We may also encourage
you to purchase a product or service when we see you. We will not disclose
your health information without your written authorization.
Food and Drug Administration (FDA)
We may disclose to the FDA your health information relating to adverse events
with respect to food, supplements, products and product defects, or post-marketing
surveillance information to enable product recalls, repairs, or replacements.
Workers' Compensation
If you are seeking compensation through Workers' Compensation, we may disclose
your health information to the extent necessary to comply with laws relating
to Workers' Compensation.
Public Health
As required by law, we may disclose your health information to public health
or legal authorities charged with preventing or controlling disease, injury,
or disability; to report reactions to medications or problems with products;
to notify people of recalls; to notify a person who may have been exposed
to a disease or who is at risk for contracting or spreading a disease or
condition.
Abuse, Neglect & Domestic Violence
We may disclose your health information to public authorities as allowed by
law to report abuse, neglect, or domestic violence.
Sign in Sheet
We may use and disclose your health information by having you sign in when
you arrive at our office. We may also call out your name when we are ready
to see you.
Inmates
If you are an inmate of a correctional institution or under the custody of a
law enforcement officer, we may disclose to the institution or law enforcement
official health information necessary for your health and the health and safety
of other individuals.
Law Enforcement
We may disclose your health information for law enforcement purposes as required
by law, such as when required by a court order; for identification of a victim
of a crime if certain protective requirements are met; to report a crime
on our premises; to report crime in emergencies; and other appropriate situations
permitted by law.
Health Oversight
We may disclose your health information to appropriate health oversight agencies
or for health oversight activities. Judicial/Administrative Proceedings We
may disclose your health information in the course of any judicial or administrative
proceeding as allowed or required by law or as directed by a proper court
order or in response to a subpoena, with your authorization, discovery request
or other lawful process if certain specific requirements are met.
Serious Threat
To avert a serious threat to health or safety, we may disclose your health
information consistent with applicable law to prevent or lessen a serious,
imminent threat to the health or safety of a person or the public.
For Specialized Governmental Functions
We may disclose your health information for specialized government functions
as authorized by law such as to Armed Forces personnel, for national security
purposes, or to public assistance program personnel.
Other Uses
Other uses and disclosures of your health information besides those identified
in this Notice will be made only as otherwise authorized by law or with your
written authorization and you may revoke the authorization as previously
provided in this Notice.
Website
If we maintain a website that provides information about our office, this Notice
will be on the website.
Research
We may disclose your health information to researchers
when their research has been approved by an institutional review
board that has reviewed the research proposal and established
protocols to ensure the privacy of your protected health information.
Fund Raising
We may contact you as part of a fund raising effort. If you do not want to receive
these materials notify our Privacy Officer.
This office is permitted by federal privacy laws to make uses
and disclosures of your health information for purposes of treatment,
payment, and health care operations. Protected health information
is the information we create and obtain in providing our services
to you. The health information about you is documented in a medical
record and on a computer. Such information may include documenting
your symptoms, medical history, examination and test results,
diagnoses, treatment, and applying for future care or treatment.
It also includes billing documents for those services.
Examples of uses of your health information for
treatment purposes are:
• A nurse or medical assistant obtains treatment
information about you and records it in a health record.
• During the course of your treatment, the physician determines he/she will need
to consult with another specialist in the area. He/she will share the information
with such specialist and obtain his/her input.
Example of use of your health information for payment
purposes:
We submit requests for payment to your health insurance company. The health
insurance company (or other business associate helping us obtain payment) requests
health information from us regarding medical care given. We will provide information
to them about you and the care given, which may include copies or excerpts
of your medical record which are necessary for payment of your account. For
example, a bill sent to your health insurance company may include information
that identifies your diagnosis, and the procedures and supplies used.
Example of use of your health information for health
care operations:
We obtain services from our insurers or other business
associates (an individual or entity under contract with us to
perform or assist us in a function or activity that necessitates
the use or disclosure of health information) such as quality
assessment, quality improvement, outcome evaluation, protocol
and clinical guidelines development, training programs, credentialing,
medical transcription, medical review, legal services, and insurance.
We will share health information about you with our insurers
or other business associates as necessary to obtain these services.
We require our insurers and other business associates to protect
the confidentiality of your health information.
Your Health Information Rights
The health and billing records we maintain are the physical property of the
doctor's office. The information in it, however, belongs to you. You have
a right to:
• Request a restriction on certain uses and disclosures of your
health information by delivering the request in writing to our
office – we are not required to grant the request but we will
comply with any request granted.
• Obtain a paper copy of the Notice of Privacy Practices for
Protected Health Information ("Notice") by making a request at
our office;
• Request that you be allowed to inspect and copy your medical
record and billing record--you may exercise this right by delivering
the request in writing to our office using the form we provide
to you upon request;
• Appeal a denial of access to your protected health information
except in certain circumstances;
• Request that your medical record be amended to correct incomplete
or incorrect information by delivering a written request, including
a reason to support it, to our office using the form we provide
to you upon request. (We are not required to make such amendments);
• File a statement of disagreement if your amendment is denied,
and require that the request for amendment and any denial be
attached in all future disclosures of your protected health information;
• Obtain an accounting of disclosures of your health information
as required to be maintained by law by delivering a written request
to our office using the form we provide to you upon request.
An accounting will not include uses and disclosures of information
for treatment, payment, or health care operations; disclosures
or uses made to you or made at your request; uses or disclosures
made pursuant to an authorization signed by you; or to family
members or friends or uses relevant to that person's involvement
in your care or in payment for such care; or uses or disclosures
to notify family or others responsible for your care of your
location, condition, or your death; we may charge a cost-based
fee for more than one accounting in a 12-month period.
• Request that confidential communication of your health information
be made by alternative means or at an alternative location by
delivering the request in writing to our office using the form
we provide to you upon request; and,
• Revoke authorizations that you made previously to use or disclose
information except to the extent information or action has already
been taken by delivering a written revocation to our office.
If you want to exercise any of the above rights, please contact
our privacy officer 16641 N. 40th Street, Suite 2, in person
or in writing, during normal business hours. Our Privacy Officer
will provide you with assistance on the steps to take to exercise
your rights.
You have the right to review this Notice before signing the
acknowledgment authorizing use and disclosure of your protected
health information for treatment, payment, and health care operations
purposes.
Our Responsibilities
The office is required to:
• Maintain the privacy of your health information as required by law;
• Provide you with a notice as to our duties and privacy practices as to the
information we collect and maintain about you;
• Abide by the terms of this Notice;
• Notify you if we cannot accommodate a requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate health
information with you.
We reserve the right to amend, change, or eliminate provisions
in our privacy practices and access practices and to enact new
provisions regarding the protected health information we maintain.
If our information practices change, we will amend our Notice.
You are entitled to receive a revised copy of the Notice by calling
and requesting a copy of our "Notice" or by visiting our office
and picking up a copy.
To Request Information or File a Complaint:
If you have questions, would like additional information,
want to report a problem regarding the handling of your information
or if you believe your privacy rights have been violated and
wish to file a written complaint with our office, please contact
our Privacy Officer at 16641 N. 40th Street, Suite 2, Phoenix,
Arizona 85032. You may also file a complaint by mailing it or
e-mailing it to the Secretary of Health and Human Services.
• We cannot, and will not, require you to waive your rights under the Privacy
Rule including the right to file a complaint with the Secretary of Health and
Human Services (HHS) as a condition of receiving treatment from the office.
• We cannot, and will not, retaliate against you for filing a complaint with
the Secretary of Health and Human Services.
Other Disclosures and Uses We Can Make Without Your
Written Authorization:
Notification of Family/Friends
Unless you object, we may use or disclose your
protected health information to notify, or assist in notifying,
a family member, personal representative, or other person responsible
for your care, about your location, and about your general condition,
or your death.
Communication with Family/Friends
Using our best judgment, we may disclose to a family member, other relative,
close personal friend, or any other person you identify, health information
relevant to that person's involvement in your care or in payment for such
care if you do not object or in an emergency.
Disaster Relief
We may use and disclose your health information
to assist in disaster relief efforts.
Employers
We may release health information about you to
your employer if we provide health care services to you at the
request of your employer, and the health care services are provided
either to conduct an evaluation relating to medical surveillance
of the workplace or to evaluate whether you have a work-related
illness or injury. In such circumstances, we will give you written
notice of such release of information to your employer. Any other
disclosures to your employer will be made only if you execute
an authorization for the release of that information to your
employer.
Original Effective Date: April 14, 2003
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