THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF OUR PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (PROTECTED HEALTH INFORMATION (PHI). This notice is REQUIRED as a result of the Health Insurance Portability Act of 1996 (HIPAA).
PLEASE REVIEW THIS NOTICE CAREFULLY.
A. WE ARE COMMITTED TO YOUR PRIVACY.
The practice of Doctors’ Steven Wilk, Nibal Zrik, & Pria Chang is dedicated to maintaining the privacy of your Protected Health Information (PHI). In conducting our business, a record containing services provided and treatment regarding those services is created. We are required by law to maintain the confidentiality of any health information that identifies you the patient. We are also required by law to provide you with this written notice of our legal duties and the privacy practices that we maintain in our practice concerning you PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time. The laws regarding this issue are complicated, but we must provide you with the following information.
- How we may use and disclose your PHI
- Your privacy rights in your PHI
- Our obligation concerning the use and disclosure of your PHI
The terms of this notice apply to all records containing your PHI that are created or retained by our practice. When we make an important change to our privacy practices, we will post a change notice in our office for all patients to review. Any changes to this notice will be effective for all records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. A copy of our current Privacy Notice is available upon request at any time.
B. OUR PRACTICE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS;
1. TREATMENT. We may use your PHI to treat you. For example, we may ask you to have laboratory tests (this could be x-rays or tissue testing), to help us reach a diagnosis and determine treatment. We might use your PHI: a) in order to write a prescription for you; b) to a pharmacy when we order a prescription for you; or c) to another physician or dentist, physician or dentist’s assistant, or physician or dentist staff who are, or are about to be, involved in your care. Many people who work for our practice including, but not limited to, our doctors and assistants may use or disclose your PHI in order to treat you or to assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.
2. PAYMENT. The practice of Doctors’ Steven Wilk, Nibal Zrik and Pria Chang may use and disclose your PHI in order to bill and collect payment for services rendered. For example, we may contact your health/dental insurer to certify that you are eligible for benefits (and for what range of benefits) and we may provide your insurer with details regarding your visit or treatment to determine if your insurer will cover, or pay for your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also we may use your PHI to bill you directly for visits and treatment. We may disclose your PHI to other health/dental providers and entities to assist in billing and collection efforts.
3. APPOINTMENT REMINDERS. Our practice may use and disclose your PHI to contact you and remind you of an appointment. This contact may be by phone, in writing or otherwise, and involve leaving a message on an answering machine which could potentially be picked up by others.
4. TREATMENT OPTIONS. Our practice may use or disclose your PHI to inform you of potential treatment options or alternatives.
5. HEALTH-RELATED BENEFITS AND SERVICES. Our practice may use and disclose your PHI to inform you of health/ dental-related benefits or services that may be of interest to you.
6. RELEASE OF INFORMATION TO FAMILY/FRIENDS. Our practice may release your PHI to a family member or friend that is involved in your care, or who assists in taking care of you. However, we would require written or verbal notice from the patient, parent, or personal representative in order for us to release your PHI to a friend or family member. For example, if someone other than the legal parent/guardian were asked to bring a person to our practice to see a provider, our practice would require that the parent/guardian (personal representative) notify our practice. Our practice would require written or verbal authorization from the parent/guardian (personal representative). Another example might be an elderly patient that is no longer able to care for him/herself. If our practice is to release PHI to a friend or family member that is not the patient’s personal representative in order to release PHI to the friend or family member.
7. DISCLOSURES REQUIRED BY LAW. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.
C. USE AND DISCLOSURE OF YOUR PHI IN SPECIAL CIRCUMSTANCES
The following describes unique situations in which we may use or disclose our identifiable health information.
1. PUBLIC HEALTH RISKS. Our practice may disclose our PHI to public health authorities that are authorized by law to collect information for the purpose of:
- Reporting child abuse or neglect.
- Preventing or controlling disease, injury or disability
- Notifying a person regarding potential risk for spreading or contracting a disease or condition.
- Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of a patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information.
2. HEALTH OVERSIGHT ACTIVITIES. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. oversight activities can include, for example, investigations, inspections, and its surveys, licensure and disciplinary action; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights and the health/dental care system in general.
3. LAWSUITS AND SIMILAR PROCEEDINGS. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, provided the appropriate paperwork to release this information is presented or unless a written order is presented from you protecting the information the party has requested.
4. LAW ENFORCEMENT. Our practice may release PHI if asked to do so by a law enforcement official.
- Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement.
- Concerning a death we. believe has resulted from criminal conduct.
- Regarding a criminal conduct at our office.
- In response to a warrant, summons, court order, subpoena or similar legal process.
- In an emergency, to report a crime (including the location or victim(s) of the crime) or the description, identity or location of the perpetrator.
5. DECEASED PATIENTS. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual. If necessary, we also may release the information in order for funeral directors to perform their jobs.
6. WORKERS COMPENSATION. Our practice may release your PHI for workers’ compensation and similar programs.
D. YOUR RIGHTS REGARDING YOUR PHI
1. CONFIDENTIAL COMMUNICATIONS. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance you may ask that we contact you at your home rather that work. In order to request a type of confidential communication, you must make a written request to the Practice Manager, specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
2. REQUESTING RESTRICTIONS. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operation. Additionally, you have the right to request that we restrict our disclosure of our PHI to only certain individuals involved in your care or the payment for our care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use of disclosure of your PHI, you must make our request in writing to our Practice Manager. Your request must describe in a clear and concise fashion:
a) the information you wish restricted;
b) whether you are requesting to limit our practice’s use, disclosure or both, and
c) to whom you want the limits to apply.
3. INSPECTION AND COPIES. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical/dental records and billing records. Yo1,1 must submit your request in writing to the Practice Manager, in order to inspect and/or obtain a copy of our PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request.
We reserve the right to deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health/dental professional chosen by us will conduct their reviews.
4. AMENDMENT. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to our Practice manager. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (bl no part of the PHI kept by or for the practice; ( c) not part of the PHI which you would be permitted to inspect and copy; or (dl not created by our practice unless the individual or entity that created the information is not available to amend the information. In all cases where a correction is made, the original uncorrected part of the PHI will be retained, with a notation that a correction has been made.
5. RIGHT TO A COPY OF THIS NOTICE. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of the notice, contact one of our staff members who will gladly provide you with a copy.
6. RIGHT TO FILE A COMPLAINT. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact the Practice Manager