Effective
Date: April 14, 2003
CAN
GET ACCESS TO THIS INFORMATION.
PLEASE
REVIEW THIS NOTICE CAREFULLY.
If you have any questions about this notice, please contact
our privacy officer:
Patriot Pediatrics office manager
74 Loomis
Street, Bedford, Ma. 01730
#781-674-2900
Patriot
Pediatrics is committed to preserving the privacy and confidentiality of your
health information, which is required both by federal and state law, as well as
by ethics of the medical profession. We
are required by law to provide you with this notice of our legal duties, your
rights, and our privacy practices, with respect to using and disclosing your
health information that is created or retained by Patriot Pediatrics.
Each time you visit us, we make a record of your
visit. Typically, this record contains
your symptoms, examination and test results, diagnoses, treatment, and a plan
for future care or treatment. We have
an ethical and legal obligation to protect the privacy of your health
information, and we will only use or disclose this information in limited
circumstances. In general, we may use
and disclose your health information to:
·
plan your care and treatment;
·
provide treatment by us or others;
·
communicate with other providers such as
referring physicians;
·
receive payment from you, your health
plan, or your health insurer;
·
make quality assessments and work to
improve the care we render and the outcomes we achieve, known as health care
operations;
·
make you aware of services and treatments
that may be of interest to you; and
·
comply with state and federal laws that
require us to disclose your health information.
We may also use or disclose your health information where
you have authorized us to do so.
You have certain rights to your health information. You have the right to:
·
ensure the accuracy of your health
record;
·
request confidential communications
between you and your physician and request limits on the use and disclosure of
your health information; and
·
request an accounting of certain uses and
disclosures of health information we have made about you.
We are required to:
·
maintain the privacy of your health information;
·
provide you with notice, such as this Notice of Privacy Practices, as to our legal duties and privacy
practices with respect to information we collect and maintain about you;
·
abide by the terms of our most current Notice of Privacy Practices;
·
notify you if we are unable to agree to a requested restriction; and
·
accommodate reasonable requests you may have to communicate health
information by alternative means or at alternative locations.
We reserve the
right to change our practices and to make the new provisions effective for all your health information that we maintain.
Should our information practices change, a revised Notice of Privacy Practices will be available upon request.
We will not use or disclose your health information without your
authorization, except as described in our most current Notice of Privacy Practices.
In the following pages, we explain our privacy practices
and your rights to your health information in more detail.
A. Treatment We may use your
medical information to provide you with medical treatment or services. For example, we may use your health
information to write a prescription or to prescribe a course of treatment. We will record your current healthcare
information in a record so, in the future, we can see your medical history to
help in diagnosing and treatment, or to determine how well you are responding
to treatment. We may provide your health
information to other health providers, such as referring or specialist
physicians, to assist in your treatment.
Should you ever be hospitalized, we may provide the hospital or its
staff with the health information it requires to provide you with effective
treatment.
B. Payment We may use and disclose your health information so that we
may bill and collect payment for the services that we provided to you. For example, we may contact your health
insurer to verify your eligibility for benefits, and may need to disclose to it
some details of your medical condition or expected course of treatment. We may use or disclose your information so
that a bill may be sent to you, your
health insurer, or a family member. The
information on or accompanying the bill may include information that identifies
you and your diagnosis, as well as services rendered, any procedures performed,
and supplies used. Also, we may provide
health information to another health care provider, such as an ambulance
company that transported you to our office, to assist in their billing and
collection efforts.
C. Health care
operations We may use and disclose your health information to assist
in the operation of our practice. For
example, members of our staff may use information in your health record to
assess the care and outcomes in your case and others like it as part of a
continuous effort to improve the quality and effectiveness of the healthcare
and services we provide. We may use and
disclose your health information to conduct cost-management and business planning
activities for our practice. We may also provide such information to other
health care entities for their health care operations. For example, we may provide information to
your health insurer for its quality review purposes.
D. Business
Associates Patriot Pediatrics sometimes contracts with third-party
business associates for services.
Examples include companies providing storage of records, testing
laboratories, transcriptionists, billing services, consultants, and legal
counsel. We may disclose your health
information to our business associates so that they can perform the job we have
asked them to do. To protect your
health information, however, we require our business associates to
appropriately safeguard your information.
E. Appointment
Reminders We may use and
disclose Information in your medical record to contact you as a reminder that
you have an appointment at Patriot Pediatrics.
We usually will call you at home the day before your appointment and
leave a message for you on your answering machine or with an individual who
responds to our telephone call. However, you may request that we provide such
reminders only in a certain way or only at a certain place. We will endeavor to accommodate all
reasonable requests.
F. Treatment
Options We may use and disclose your health information in order to
inform you of alternative treatments.
G. Release to
Family/Friends Our health
professionals, using their professional judgment, may disclose to a family
member, other relative, close personal friend or any other person you identify,
your health information to the extent it is relevant to that person’s
involvement in your care or payment related to your care. We will provide you with an opportunity to
object to such a disclosure whenever we practicably can do so. We may disclose the health information of
minor children to their parents or guardians unless such disclosure is
otherwise prohibited by law.
H. Health-Related
Benefits and Services We may use and disclose health information to tell you about
health-related benefits or services that may be of interest to you. In face- to-face communications, such as
appointments with your physician, we may tell you about other products and
services that may be of interest you.
I. Newsletters
and Other Communications We may use your
personal information in order to communicate to you via newsletters, mailings,
or other means regarding treatment options, health related information,
disease-management programs, wellness programs, or other community based
initiatives or activities in which our practice is participating.
J. Disaster
Relief We may disclose your health
information in disaster relief situations where disaster relief organizations
seek your health information to coordinate your care, or notify family and
friends of your location and condition.
We will provide you with an opportunity to agree or object to such a
disclosure whenever we practicably can do so.
K. Marketing In most circumstances, we are required by law to receive
your written authorization before we use or disclose your health information
for marketing purposes. However, we may
provide you with promotional gifts of nominal value. Under no circumstances will we sell our patient lists or your
health information to a third party without your written authorization.
L. Fundraising. We may contact you
as part of a fundraising effort relating to the practice.
M. Public Health
Risks. We may disclose medical information about you for public
health activities. These activities
generally include the following:
·
licensing and certification carried out by public health authorities;
·
prevention or control of disease, injury, or disability;
·
reports of births and deaths;
·
reports of child abuse or neglect;
·
notifications to people who may have been exposed to a disease or may
be at risk for contracting or spreading a disease or condition;
·
organ or tissue donation; and
·
notifications to appropriate government authorities if we believe a
patient has been the victim of abuse, neglect, or domestic violence. We will make this disclosure when required
by law, or if you agree to the disclosure, or when authorized by law and in our
professional judgment disclosure is required to prevent serious harm.
N. Funeral
Directors We may disclose health information to funeral directors so
that they may carry out their duties.
O. Food and Drug
Administration (FDA) We may disclose to the FDA and
other regulatory agencies of the federal and state government health
information relating to adverse events with respect to food, supplements,
products and product defects, or post-marketing monitoring information to
enable product recalls, repairs, or replacement.
P. Psychotherapy
Notes Under most circumstances, without
your written authorization we may not disclose the notes a mental health
professional took during a counseling session.
However, we may disclose such notes for treatment and payment purposes,
for state and federal oversight of the mental health professional, for the
purposes of medical examiners and coroners, to avert a serious threat to health
or safety, or as otherwise authorized by law.
Q. Research We may disclose your health information to researchers when
the information does not directly identify you as the source of the information
or when a waiver has been issued by an institutional review board or a privacy
board that has reviewed the research proposal and protocols for compliance with
standards to ensure the privacy of your health information.
R. Workers
Compensation
We may
disclose your health information to the extent authorized by and to the extent
necessary to comply with laws relating to workers compensation or other similar
programs established by law.
S. Law
Enforcement We may release your health information:
·
in response to a court order, subpoena, warrant, summons, or similar
process if authorized under state or federal law;
·
to identify or locate a suspect, fugitive, material witness, or similar
person;
·
about the victim of a crime if, under certain limited circumstances, we
are unable to obtain the person’s agreement;
·
about a death we believe may be the result of criminal conduct;
·
about criminal conduct at [name of provider];
·
to coroners or medical examiners;
·
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;
·
to authorized federal officials for intelligence, counterintelligence,
and other national security authorized by law; and
·
to authorized federal officials so they may conduct special
investigations or provide protection to the President, other authorized
persons, or foreign heads of state.
T. De-identified
Information. We may use your health
information to create "de-identified" information or we may disclose
your information to a business associate so that the business associate can
create de-identified information on our behalf. When we "de-identify" health information, we remove
information that identifies you as the source of the information. Health information is considered
"de-identified" only if there is no reasonable basis to believe that
the health information could be used to identify you.
U. Personal
Representative If you have a personal representative, such as a legal
guardian, we will treat that person as if that person is you with respect to
disclosures of your health information.
If you become deceased, we may disclose health information to an executor
or administrator of your estate to the extent that person is acting as your
personal representative.
V. HLTV-III Test If we perform the
HLTV-III test on you (to determine if you have been exposed to HIV), we will not
disclose the results of the test to anyone but you without your written consent
unless otherwise required by law. We
also will not disclose the fact that you have taken the test to anyone without
your written consent unless otherwise required by law.
W. Limited Data
Set We may use and disclose a limited data set that does not
contain specific readily identifiable information about you for research,
public health, and health care operations.
We may not disseminate the limited data set unless we enter into a data
use agreement with the recipient in which the recipient agrees to limit the use
of that data set to the purposes for which it was provided, ensure the security
of the data, and not identify the information or use it to contact any individual.
Uses of medical information not covered by our most current Notice of Privacy Practices or the laws
that apply to us will be made only with your written authorization.
If you provide us with authorization to use or disclose medical
information about you, you may revoke that authorization, in writing, at any
time. If you revoke your authorization,
we will no longer use or disclose medical information about you for the reasons
covered by your written authorization, except to the extent that we have
already taken action in reliance on your authorization or, if the authorization
was obtained as a condition of obtaining insurance coverage and the insurer has
the right to contest a claim or the insurance coverage itself. We are unable to take back any disclosures
we have already made with your authorization, and we are required to retain our
records of the care that we provided to you.
You have the following rights regarding medical information we gather
about you:
A. Right to
Obtain a Paper Copy of This Notice. You have the right to a paper
copy of this Notice of Privacy Practices
at any time. Even if you have agreed to
receive this notice electronically, you are still entitled to a paper copy.
B. 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. Usually, this includes medical and billing records, but does not
include psychotherapy notes.
To inspect and copy medical information, you must submit a written
request to our privacy officer. We will
supply you with a form for such a request.
If you request a copy of your medical information, we may charge a
reasonable fee for the costs of labor, postage, and supplies associated with
your request. We may not charge you a
fee if you require your medical information for a claim for benefits under the
Social Security Act (such as claims for Social Security, Supplemental Security
Income, and MassHealth benefits) or any other state or federal needs-based
benefit program.
We may deny your request to inspect and copy in certain
limited circumstances. If you are
denied access to medical information, you may request that the denial be
reviewed. A licensed healthcare
professional who was not directly involved in the denial of your request will
conduct the review. We will comply with
the outcome of the review.
C. 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 we retain the information.
To request an amendment, your request must be made in writing and submitted
to our 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:
·
was not created by us, unless the person or entity that created the
information is no longer available to make the amendment;
·
is not part of the medical information kept by or for Patriot
Pediatrics;
·
is not part of the information which you would be permitted to inspect
and copy; or
·
is accurate and complete.
If we deny your request for amendment, you may submit a statement of
disagreement. We may reasonably limit
the length of this statement. Your letter
of disagreement will be included in your medical record, but we may also
include a rebuttal statement.
D. Right to an
Accounting of Disclosures. You have the right to request an accounting of disclosures of your
health information made by us. In your
accounting, we are not required to list certain disclosures, including:
·
disclosures made for treatment, payment, and health care operations
purposes or disclosures made incidental to treatment, payment, and health care
operations;
·
disclosures made pursuant to your authorization;
·
disclosures made to create a limited data set;
·
disclosures made directly to you.
To request an accounting of disclosures, you must submit your request
in writing to our privacy officer. Your
request must state a time period which may not be longer than six years and may
not include dates before April 14, 2003.
Your request should indicate in what form you would like the accounting
of disclosures (for example, on paper or electronically by e-mail). The first accounting of disclosures you
request within any 12 month period will be free. For additional requests within the same period, we may charge you
for the reasonable costs of providing the accounting of disclosures. We will notify you of the costs involved and
you may choose to withdraw or modify your request at that time, before any
costs are incurred. Under limited
circumstances mandated by federal and state law, we may temporarily deny your
request for an accounting of disclosures.
E. 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 communicate about you to someone who is involved
in your care or the payment for your care.
We are not required to agree to your request. If we do agree, we will comply with your request unless the
restricted information is needed to provide you with emergency treatment.
To request restrictions, you must make your request in writing to our
privacy officer. In your request, you
must tell us:
·
what information you want to limit;
·
whether you want to limit our use, disclosure, or both; and
·
to whom you want the limits to apply.
F. 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.
To request confidential communications, you must make your request in writing
to our 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.
If you believe your privacy rights have been violated, you may file a
complaint with us or with the Secretary of the U.S. Department of Health and
Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. To file a complaint with us, contact our
privacy officer at the address listed above. All complaints must be submitted in writing and should be
submitted within 180 days of when you knew or should have known that the
alleged violation occurred. See the
Office for Civil Rights website, www.hhs.gov/ocr/hipaa/
for more information.
You will not be penalized for filing
a complaint.