This notice describes how health information about you may be
used and disclosed and how you can get access to this
information. Please review if carefully. The privacy of your
health information is important to us.
OUR LEGAL DUTY
Federal and state law requires us
to maintain the privacy of your health information. That law
requires us to give you this notice about our privacy practices,
our legal duties, and your rights concerning your health
information. We must follow the privacy practices we describe in
this notice while it is in effect. This notice takes effect
April 14, 2003, and will remain in effect until we replace it.
We reserve the right to change privacy practices and the terms
of this notice at any time, provided such applicable law permits
the changes. We reserve the right to make the changes in our
privacy practices and the new terms of our notice effective for
all health information that we maintain, including health
information we created or received before we make the changes.
Before we make significant change in our privacy practices, we
will change this notice and make the new notice available upon
request.
You may request a copy of our notice at any time. For more
information about our privacy practices, or for any additional
copies of this notice, please contact us using the information
listed at the end of this notice.
USES AND
DISCLOSURES OF HEALTH INFORMATION
We use and disclose health
information about you for treatment, payment, and health care
operations. For example:
Treatment: We may use your health information for
treatment or disclose it to a dentist, physician or other health
care provider providing treatment to you.
Payment: We may use and disclose your health information
for our health care operations. Health care operations include
quality assessment and improvement activities, reviewing the
competence or qualifications or health care professionals,
evaluating practitioner and provider performances, conducting
training programs, accreditation, certification, licensing or
credentialing activities. We may disclose your health
information to another health care provider or organization that
is subject to the federal privacy rules and that has a
relationship with you to support some of their health care
operations. We may disclose your information to help these
organizations conduct quality assessment and improvement
activities, review the competence or qualifications of health
care professionals, or detect or prevent health care fraud and
abuse.
On Your Authorization: You may give us written
authorization to use your health information or to disclose it
to anyone for any purpose. If you give us an authorization, you
may revoke it in writing at any time. Your revocation will not
affect any uses or disclosures permitted by your authorization
while it was in effect. Unless you give us a written
authorization, we cannot use or disclose your health information
for any reason except those described in this notice.
To Your Family and Friends: We may disclose your health
information to a family member, friend or other person to the
extent necessary to help with your health care or with payment
for your health care. Before we disclose your health information
to these people, we will provide you with an opportunity to
object to our use or disclosure. If you are not present, or in
the event of your incapacity or an emergency, we will disclose
your medical information based on our professional judgment of
whether the disclosure would be in your best interest. WE may
use our professional judgment and our experience with common
practice to make reasonable inferences of your best interest in
allowing a person to pick up filled prescriptions, medical
supplies, x-rays, or other similar forms of health information.
We may use or disclose information about you to notify or assist
in notifying a person involved in your care, of your location
and general condition.
Appointment Reminders: We may use or disclose your health
information to provide you with appointment reminders (such as
voicemail messages, postcards, or letters.)
Disaster Relief: We may use or disclose your health
information to a public or private entity authorized by law or
by its charter to assist in disaster relief efforts.
Public Benefit: We may use or disclose your health
information as authorized by law for the following purposes
deemed to be in the public interest or benefit:
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as required by law; |
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for public health
activities, including disease and vital statistic
reporting, child abuse reporting, FDA oversight, and to
employers regarding work-related illness or injury; |
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to report adult abuse,
reflect, or domestic violence; |
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to health oversight
agencies; |
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in response to court and
administrative orders and other lawful purposes; |
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to law enforcement officials
pursuant to subpoenas and other lawful purposes,
concerning crime victims, suspicious deaths, crimes on
our premises, reporting crimes in emergencies, and for
purposes of identifying or locating a suspect or other
person; |
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to coroners, medical
examiners, and funeral directors; |
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to organ procurement
organizations; |
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to avert a serious threat to
health or safety; |
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in connection with certain
research activities; |
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to the military and to
federal officials for lawful intelligence,
counterintelligence, and national security activities; |
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to correctional institutions
regarding inmates; and |
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as authorized by state
worker's compensation laws. |
PATIENT RIGHTS
Access:
You have the right to look at or get copies of your health
information, with limited exceptions. You may request that we
provide copies in a format other than photocopies. We will use
the format you request unless we cannot practicably do so. You
must make a request in writing to obtain access to your health
information. You may request access by sending us a letter to
the address at the end of this notice. If you request copies, we
will charge you a reasonable cost-based fee that may include
labor, copying costs, and potage. If you request an alternative
format, we will charge a cost-based fee for providing your
health information in that format. IF you prefer, we may - but
are not required to - prepare a summary or an explanation of
your health information for a fee. Contact us using the
information listed at the end of this notice for more
information about fees.
Disclosure Accounting: You have the right to receive a
list of the instances in which we or our business associated
disclosed your health information over the last 6 years (but not
before April 14, 2003). That list will no include disclosures
for treatment, payment, health care operations, as authorizes by
you, and for certain other activities. If you request this
accounting more than once in a 12-month period, we may charge
you a reasonable, cost-based fee for responding to these
additional requests. Contact us using the information listed at
the end of this notice for more information about fees.
Restriction: You have the right to request that we place
additional restrictions on our use or disclosure of your health
information. We are not required to agree to these additional
restrictions, but it we do, we will abide by our agreement
(except in an emergency). Any agreement we may make to a request
for additional restrictions must be in writing signed by a
person authorized to make such an agreement on our behalf. You
request is not binding unless our agreement is in writing.
Alternative Communication: You have the right to request
that we communicate with you about your health information by
alternative means or to alternative locations. You must make
your request in writing. You must specify in your request the
alternative means or location, and provide satisfactory
explanation how you will handle payment under the alternative
means or location you request.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy policy practices
or have questions or concerns, please contact us using the
information listed at the end of this notice.
If you believe that:
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we may have violated your
privacy rights, |
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we made a decision about
access to your health information incorrectly, |
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our response to a request
you made to amend or restrict the use or disclosure of
your health information was incorrect, or |
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we should communicate with
you by alternative means or at alternative locations, |
you may contact us using the
information listed below. You may also submit a written
complaint to the U.S. Department of Health and Human Services.
We will provide you with the address to file your complaint with
the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information.
We will not retaliate in any way if you choose to file a
complaint with us or with the U.S. Department of Health and
Human Services.