NOTICE OF PRIVACY PRACTICES
For
DEAN FOCHIOS, M.D., P.C., DANIELBOWMAN, M.D., P.C. &
FOXCARE ORTHOPAEDICS
(referred to in this document as “the provider”)
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.
This
Notice of Privacy Practices is being provided to you as a requirement of the
Health Insurance Portability and Accountability Act (HIPAA). This Notice describes how we may use and
disclose your protected health information 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 protected health information in some cases. Your "protected health information"
means any of your written and oral health information, including demographic
data that can be used to identify you.
This is health information that is created or received by your health
care provider, and that relates to your past, present or future physical or
mental health or condition.
I. Uses and Disclosures
of Protected Health Information
The
provider may use your protected health information for purposes of providing
treatment, obtaining payment for treatment, and conducting health care
operations. Your protected health
information may be used or disclosed only for these purposes unless the
Provider has obtained your authorization or the use or disclosure is otherwise
permitted by the HIPAA Privacy Regulations or State law. Disclosures of your protected health
information for the purposes described in this Notice may be made in writing,
orally, or by facsimile.
A. Treatment. We will use and
disclose your protected health information to provide, coordinate, or manage
your health care and any related services.
This includes the coordination or management of your health care with a
third party for treatment purposes. For
example, we may disclose your protected health information to a pharmacy to
fulfill a prescription, to a laboratory to order a blood test, or to a home
health agency that is providing care in your home. We may also disclose protected health information to other
physicians who may be treating you or consulting with your physician with
respect to your care. In some cases, we
may also disclose your protected health information to an outside treatment
provider for purposes of the treatment activities of the other provider.
B. Payment. Your protected health
information will be used, as needed, to obtain payment for the services that we
provide. This may include certain
communications to your health insurer to get approval for the treatment that we
recommend. For example, if a hospital
admission is recommended, we may need to disclose information to your health
insurer to get prior approval for the hospitalization. We may also disclose protected health
information to your insurance company to determine whether you are eligible for
benefits or whether a particular service is covered under your health
plan. In order to get payment for your
services, we may also need to disclose your protected health information to your
insurance company to demonstrate the medical necessity of the services or, as
required by your insurance company, for utilization review. We may also disclose patient information to
another provider involved in your care for the other provider’s payment
activities.
C. Operations. We may use or disclose
your protected health information, as necessary, for our own health care
operations in order to facilitate the function of the provider and to provide
quality care to all patients. Health
care operations include such activities as:
· Quality assessment and improvement activities.
·
Employee review activities.
·
Training programs including those in which
students, trainees, or practitioners in health care learn under supervision.
·
Accreditation, certification, licensing or
credentialing activities.
·
Review and auditing, including compliance
reviews, medical reviews, legal services and maintaining compliance programs.
·
Business management and general administrative
activities.
In certain situations, we
may also disclose patient information to another provider or health plan for
their health care operations.
D. Other Uses and
Disclosures. As part of treatment, payment and healthcare operations, we may
also use or disclose your protected health information for the following
purposes:
·
To remind you of an appointment.
·
To inform you of potential treatment
alternatives or options.
·
To inform you of health-related benefits or
services that may be of interest to you.
·
To contact you to raise funds for the provider
or an institutional foundation related to the provider. If you do not wish to be contacted regarding
fundraising, please contact our Privacy Officer.
II.
Uses and Disclosures Beyond Treatment, Payment, and Health Care
Operations Permitted Without Authorization or Opportunity to Object
Federal privacy rules
allow us to use or disclose your protected health information without your
permission or authorization for a number of reasons including the
following:
A. When Legally Required. We will disclose your protected health information when we are required to do so by any Federal, State or local law.
B. When There Are Risks to Public Health. We may disclose your protected health information for the following public activities and purposes:
· To prevent, control, or report disease, injury or disability as permitted by law.
· To report vital events such as birth or death as permitted or required by law.
· To conduct public health surveillance, investigations and interventions as permitted or required by law.
· To collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.
· To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.
· To report to an employer information about an individual who is a member of the workforce as legally permitted or required.
C. To Report Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe that a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.
D. To Conduct Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law. We will not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.
E. In
Connection With Judicial And Administrative Proceedings. We may disclose your protected health
information in the course of any judicial or administrative proceeding in
response to an order of a court or administrative tribunal as expressly
authorized by such order or in response to a subpoena in some circumstances.
F. For Law Enforcement Purposes. We may disclose your protected health information to a law enforcement official for law enforcement purposes as follows:
G. To Coroners, Funeral Directors, and for Organ Donation. We may disclose protected health information to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information 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. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
H. For Research Purposes. We may use or disclose your protected health information for research when the use or disclosure for research has been approved by an institutional review board or privacy board that has reviewed the research proposal and research protocols to address the privacy of your protected health information.
I. In the Event of A Serious Threat To Health Or Safety. We may, consistent with applicable law and ethical standards of conduct, use or disclose your protected health information if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
J. For Specified Government Functions. In certain circumstances, the Federal regulations authorize the provider to use or disclose your protected health information to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.
K. For Worker's Compensation. The provider may release your health information to comply with worker's compensation laws or similar programs.
III.
Uses and Disclosures Permitted Without Authorization But With
Opportunity to Object
We
may disclose your protected health information to your family member or a close
personal friend if it is directly relevant to the person’s involvement in your
care or payment related to your care.
We can also disclose your information in connection with trying to
locate or notify family members or others involved in your care concerning your
location, condition or death.
You may object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to the person’s involvement with your care, we may disclose your protected health information as described.
IV. Uses
and Disclosures Which You Authorize
Other than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.
You have the following rights regarding your health information:
A. The right to
inspect and copy your protected health information. You may inspect and obtain a copy of your protected health
information that is contained in a designated record set for as long as we
maintain the protected health information.
A “designated record set” contains medical and billing records and any
other records that your physician and the provider uses for making decisions about
you.
Under Federal law,
however, you may not inspect or copy the following records: psychotherapy notes; information compiled in
reasonable anticipation of, or for use in, a civil, criminal, or administrative
action or proceeding; and protected health information that is subject to a law
that prohibits access to protected health information. Depending on the circumstances, you may have
the right to have a decision to deny access reviewed.
We may deny your request
to inspect or copy your protected health information if, in our professional
judgment, we determine that the access requested is likely to endanger your
life or safety or that of another person, or that it is likely to cause
substantial harm to another person referenced within the information. You have the right to request a review of
this decision.
To inspect and copy your medical
information, you must submit a written request to the Privacy Officer whose
contact information is listed on the last pages of this Notice. If you request a copy of your information,
we may charge you a fee for the costs of copying, mailing or other costs
incurred by us in complying with your request.
Please contact our Privacy
Officer if you have questions about access to your medical record.
B. The right to request
a restriction on uses and disclosures of your protected health information. You may ask us not to use
or disclose certain parts of your protected health information for the purposes
of treatment, payment or health care operations. You may also request that we not disclose your health information
to family members or friends who may be involved in your care or for
notification purposes as described in this Notice of Privacy Practices. Your request must state the specific
restriction requested and to whom you want the restriction to apply.
The provider is not
required to agree to a restriction that you may request. We will notify you if we deny your request
to a restriction. If the provider does
agree to the requested restriction, we may not use or disclose your protected
health information in violation of that restriction unless it is needed to
provide emergency treatment. Under
certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting
the Privacy Officer.
C. The right to
request to receive confidential communications from us by alternative means or
at an alternative location. You have the right to request that we communicate with you in
certain ways. We will accommodate
reasonable requests. We may 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 require you to
provide an explanation for your request.
Requests must be made in writing to our Privacy Officer.
D. The right to
have your physician amend your protected health information. You may request an
amendment of protected health information about you in a designated record set
for as 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. Requests for amendment must
be in writing and must be directed to our Privacy Officer. In this written request, you must also
provide a reason to support the requested amendments.
E. The right to
receive an accounting. You have the right to request an accounting of certain
disclosures of your protected health information made by the provider. This right applies
to disclosures for purposes other than treatment, payment or health care
operations as described in this Notice of Privacy Practices. We are also not required to account for
disclosures that you requested, disclosures that you agreed to by signing an
authorization form, disclosures for a facility directory, to friends or family
members involved in your care, or certain other disclosures we are permitted to
make without your authorization. The
request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period
sought for the accounting. We are not
required to provide an accounting for disclosures that take place prior to
April 14, 2003. Accounting requests may
not be made for periods of time in excess of six years. We will provide the first accounting you
request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable
cost-based fee.
F. The right to
obtain a paper copy of this notice. Upon request, we will provide a separate
paper copy of this notice even if you have already received a copy of the
notice or have agreed to accept this notice electronically.
VI. Our Duties
The provider is required by law to
maintain the privacy of your health information and to provide you with this
Notice of our duties and privacy practices.
We are required to abide by terms of this Notice as may be amended from
time to time. We reserve the right to
change the terms of this Notice and to make the new Notice provisions effective
for all protected health information that we maintain. If the provider changes its Notice, we will
provide a copy of the revised Notice by sending a copy of the Revised Notice
via regular mail or through in-person contact.
VII. Complaints
You have the right to express
complaints to the provider and to the Secretary of Health and Human Services if
you believe that your privacy rights have been violated. You may complain to the provider by
contacting the provider’s Privacy Officer verbally or in writing, using the
contact information below. We encourage
you to express any concerns you may have regarding the privacy of your
information. You will not be retaliated
against in any way for filing a complaint.
The provider’s contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. Complaints against the provider can be mailed to the Privacy Officer by sending it to:
Office Administrator
One FoxCare Drive Suite 211
Oneonta, NY 13820
ATTN: Privacy Officer
The Privacy Officer can be contacted by telephone at 607-432-2239
This Notice is effective May 1, 2006.
FoxCare ORTHOPAEDICS
DEAN FOCHIOS, M.D., P.C., &
DANIEL BOWMAN, M.D., P.C.
Notice and Acknowledgement
Acknowledgement:
I
acknowledge that I have received the attached Notice of Privacy Practices.
____________________________ _______________
Patient
or Personal Representative Date
Signature
____________________________
_______________
Printed Name of Patient
Account #
If
Personal Representative’s signature appears above, please describe Personal
Representative’s
relationship to the patient:
_______________________________________________________________