This notice takes effect on April 14, 2003 and remains in effect until we replace it.
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
I. OUR PLEDGE REGARDING MEDICAL INFORMATION
The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you abut the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.
II. OUR LEGAL DUTY
LAW REQUIRES US TO:
- Keep your medical information private.
- Give you this notice describing our legal duties, privacy practices. and your rights regarding your medical information.
- Follow the terms ofthe notice that is now in effect.
WE HAVE THE RIGHT TO:
- Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.
- Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.
NOTICE OF CHANGE TO PRIVACY PRACTICES:
Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.
III USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways that we use and disclose medical information. For each kind of use or disclosure, we will explain what we mean and give an example. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us.
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 doctors, nurses, technicians, medical students, or other people who are taking care of you.
Example: Your child is in the hospital for severe asthma attack. Your child also has diabetes. A number of health care and support staff need to know about your child's diabetes during your stay:
- The other doctors treating your child while in the hospital needs to know if your child has diabetes to continue existing treatment and prevent complications.
- The dietitian needs to know about your child's diabetes to arrange proper meals.
- The pharmacy needs to know about possible medicines that your child may need as a diabetic.
We may also share medical information about you to your other health care providers to assist them in treating you.
FOR PAYMENT:
We may use and disclose your medical information for payment purposes.
Example:
Your child is treated in our office for a severe asthma attack.
- We may need to give your health insurance plan information about a treatment you received at our organization so that your health plan will pay us or repay you for the treatment that you received.
- We may also tell your health plan about a treatment you are going to receive to get approval or to determine if your plan will pay for the treatment.
FOR HEALTH CARE OPERATIONS:
We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.
Example:
We may use medical information to review our treatment and services to evaluate the performance of our staff in caring for you.
ADDITIONAL USES AND DISCLOSURES:
In addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purposes.
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 in the hospital or office. Our automated phone system will provide limited appointment information as a reminder on your home answering machine, voice mail, or with the person who answers the phone.
TREATMENT ALTERNATIVES:
Wo may use and disclose medical information to tell you or recommend possible treatment options and alternatives or health-related benefits or services that may be of interest to you.
DISASTER RELIEF:
Medical information with a public or private organization or person who can legally assist in disaster relief efforts.
RESEARCH IN LIMITED CIRCUMSTANCES:
Medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information.
FUNERAL DIRECTOR, CORONER, MEDICAL EXAMINER:
To help them carry out their duties, we may share the medical information of a person who has died with a
coroner, medical examiner, funeral director, or an organ procurement organization.
SPECIALIZED GOVERNMENT FUNCTIONS:
Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
COURT ORDER AND JUDICIAL AND ADMINTSTRATIVE PROCEESINGS:
We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or law enforcement official or correctional institution under certain circumstances.
PUBLIC HEALTH ACTIVITIES:
As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration (FDA) for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the FDA. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.
VICTIMS OF ABUSE, NEGLECT OR DOMESTIC VIOLENCE:
We may disclose medical 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 share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. We may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.
HEALTH OVERSIGHT ACTIVITIES:
We may disclose medical information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, lie ensure or disciplinary actions, or other authorized activities.
LAW ENFORCEMENT:
Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
YOU HAVE A RIGHT TO:
- Inspect and copy medical information that may be used to make decisions about your care. You must make your request in writing. You may also request access by sending a letter to the contact person listed at the end of this notice or calling to get a request form.
- Request an "accounting of disclosures". This is a list of the disclosures we made of medical information about you. To request this list, you must submit your request m writing to the contact person listed at the end of this notice. Your request must slate a time period which may not be longer than six years and may not include dates before April 15,2003.
- Request a restrictions 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. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency). This request must also be in writing to the contact person listed at the end of this notice. 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.
- Request an amendment to your medical information, if you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. We may deny your request if we did not create the information you want changed or for certain other reasons. This request must be made in writing to the contact person listed in the back of this notice. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.
- Request confidential communications. You have the right to request 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. This request must be in writing to the contact person listed in the back of this notice. We will not ask you the reason for your request. We will accommodate all reasonable requests. The request must specify how or where you wish to be contacted.
- Paper copy of this notice. You may ask us to give you a copy of this notice at any time. You may obtain a copy of this notice at our website,
www.pediatricsoffranklin.com.
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Carol Hawkins, FACMPE Privacy Officer
Pediatric Associates 0f Franklin
570 Bakers Bridge Franklin, TN 37067
615-790-3200
615-794-2883 fax
If you think we may have violated your privacy rights, contact the person named above. All complaints must be submitted in writing. You may also submit a written complaint to the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.