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(“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.”)
Our Legal Duty
The Center for Applied Reproductive Science (CARS) has in
the past and will continue to keep information about you in
the strictest of confidence and to keep you informed of your
rights as our patient. Effective April 14, 2003, CARS is required
by federal privacy laws to make uses and disclosures known
to you of information gained or shared about you in the course
of your care. This information, called "Protected Health
Information", is the total collection of the information
that we create or obtain in providing our services to you.
Examples of such information may include but are not limited
to documentation of your medical, social and personal history,
problems and symptoms, examination and test results, diagnoses
and treatment.
Individual Rights
As a standard practice, CARS will not use or disclose your
information for any reason without your written permission.
As a service to you CARS will file claims for our services
with your insurance company. As such, your insurance company
has the right to medical information covering your claim.
By law, you have the right to request in writing to the CARS
Privacy Officer that CARS not disclose any of your health
information to others except when specifically authorized
by you except when required by law, or in emergency circumstances
where this information is essential for your care. You also
have the right to receive a list of instances where CARS may
have disclosed medical information about you for reasons other
than treatment, payment or related administrative purposes.
CARS will consider and make every effort to accommodate any
reasonable request, but is not legally required to accept
it. In order to obtain a description of disclosures, you must
submit your request in writing to the CARS Privacy Officer.
You have the right to look at or obtain
a copy of your health information file. If you request copies
of your medical record, CARS reserves the right by law to
charge you a processing fee. If you believe information in
your record is incorrect or if important information is missing,
you have the right to request in writing to the CARS Privacy
Officer, or your physician, to correct or add the missing
information. We will review thoroughly any request for changes,
but by law are not required to agree to your request. If your
amendment is denied, you do have the right to file a statement
of disagreement in writing. You also have the right to require
that your written request for amendment and any denial be
attached to your medical record.
Uses and Disclosures of Your
Health Information
CARS may use medical information about you for treatment,
to obtain payment for treatment, for administrative purposes,
and to evaluate the quality of care that you receive. CARS
may be required by law to disclose medical information about
you without your authorization for several reasons. An example
of disclosure would be during the course of your treatment,
if the physician determines he/she will need to consult with
another specialist in the area, he/she would share the information
with such specialist and obtain his/her input. CARS may also
be required to disclose medical information about you without
your authorization for public health purposes, for research
studies (in certain limited circumstances where you will not
be identified by name), workers compensation, for emergencies
and for law enforcement in specific circumstances. In any
other situation, CARS will ask for your written authorization
before using or disclosing any medical information about you.
If you choose to sign an authorization to disclose your medical
information, by law you have the right to later revoke that
authorization to stop any future uses and disclosures.
CARS reserves the right to make changes
to our policies at any time. Before CARS will make any significant
changes in our policies, we will change our notice and post
the new notice in our offices in a visible location. You may
also request a copy of our notice at any time. For more information
about our privacy practices, please contact our CARS Privacy
Officer.
Complaints
If you are concerned that CARS may have violated your privacy
rights, or if you disagree with a decision CARS made about
access to your records, you may contact the Privacy Officer
for this practice at the address listed above. You also may
send a written complaint to the U.S. Department of Health
and Human Services, 200 Independence Ave., S.W., Washington,
D.C. 20201. We cannot and will not require you to waive the
right to file a complaint, nor can we or will we retaliate
against you for filing a complaint.
I ____________________________________________,
have received a copy of the Notice of Privacy Practices for
CARS and understand my rights as their patient.
_____________________________________________
______________________________
(Patient Signature) (Date)
PLEASE RETURN THIS FORM AT YOUR
INITIAL CONSULTATION VISIT.
We may use and disclose your Individually Identifiable Health
Information (IIHI) in the following ways.
1. Treatment purposes: Our practice may
use your IIHI to treat you. For example, we may ask you to
have lab tests (such as blood or urine tests), and we may
use the results to help us reach a diagnosis. We might use
your IIHI in order to write a prescription for you, or we
might disclose your IIHI to a pharmacy when we order a prescription
for you. Many of CARS staff (including, but not limited to,
our doctors and nurses) may use or disclose your IIHI in order
to treat you or to assist others in your treatment. We may
also disclose your IIHI to other health care providers for
purposes related to your treatment.
2. Payment: Our practice may use and disclose your IIHI in
order to bill and collect payment for the services and items
you may receive from us. For example, we may contact your
health 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 treatment to determine
if your insurer will cover, or pay for your treatment. We
also may use and disclose your IIHI to obtain payment from
third parties that may be responsible for such costs, such
as family members. Also, we may use your IIHI to bill you
directly for services and items.
Health Care Operations: CARS may use
and disclose our IIHI to operate our business. Examples of
the ways in which we may use and disclose your information
for our operations would be, our practice may use your IIHI
to evaluate the quality of care you received from us, or to
conduct cost-management and business planning activities for
our practice. We may disclose your IIHI to other health care
providers and entities to assist in their health care operations.
4. Disclosures Required By Law: CARS
will use and disclose your IIHI when we are required to do
so by federal, state or local law.
5. Patient Contact: We may contact you
to provide you with appointment reminders, with information
about treatment , or with information about other health related
benefits and services that may be of interest to you. We may
contact you as part of a fund raising effort.
6. Notification – Opportunity to
Agree or Object: Unless you object we may use or disclose
your protected health information to notify, or assist in
notifying a family member, personal representative or other
person responsible for your care, about your location and
about your general condition or in the event of your death.
Communication with Family: Using our
best judgement, we may disclose to a family member, other
relatives, close friend or any other person you identify,
health information relevant to that person’s involvement
in your care or in payment for such care if you do not object
or in an emergency.
We may use and disclose your protected health information
to assist in disaster relief efforts.
The health and billing records we maintain
are the physical property of the doctor’s office. The
following is a review of your rights with respect to your
Protected Health Information.
Request a restriction on certain uses
and disclosures of your health information by delivering the
request in writing to our office. We are not required to grant
the request but we will comply with any request granted.
Obtain a paper copy of the Notice of Privacy Practices for
Protected Health Information by making a request at our office.
Right to inspect and copy your health
and billing record. You may exercise this right by delivering
the request in writing to our office using the form we provide
to you upon request. You may appeal a denial of access to
your protected health information except in certain circumstances.
Right to request that your health care
record be amended to correct incomplete or incorrect information
by delivering a written request to our office using the form
we provide to you upon request. The physician or other health
care provider is not required to make such amendments. You
may file a statement of disagreement if your amendment is
denied, and require that the request for amendment and any
denial be attached in all future disclosures of your protected
health information.
Right to receive an accounting of disclosures of your health
information as required to be maintained by law by delivering
a written request to our office using the form we provide
to you upon request. An accounting will not include internal
uses of information for treatment, payment, or operations,
disclosures made to you or made at your request, or disclosures
made to family members or friends in the course of providing
care.
Right to confidential communication
by requesting that communication of your health information
be made by alternative means or at an alternative location
by delivering the request in writing to our office using the
form we give you upon request.
If you want to exercise any of the above
rights, please contact our Privacy Officer at 408 N. State
of Franklin Rd., Suite 31, Johnson City, TN 37604, (423) 461-8880,
in person or in writing, during normal hours. He/she will
provide you with assistance on the steps to take to exercise
your rights.
Following is a List of Other
Uses and Disclosures Allowed by the Privacy Rule.
PUBLIC HEALTH ACTIVITIES
Controlling Disease – As required by law, we may disclose
your protected health information to public health or legal
authorities charged with preventing or controlling disease,
injury, or disability.
Child Abuse & Neglect
– We may disclose protected health information to public
authorities as allowed by law to report child abuse or neglect.
Food and Drug Administration
(FDA) – We may disclose to the FDA your protected
health information relating to adverse events with respect
to food, supplements, products and product defects, or post-marketing
surveillance information to enable product recalls, repairs,
or replacements.
VICTIMS OF ABUSE, NEGLECT, OR
DOMESTIC VIOLENCE
We can disclose protected health information to governmental
authorities to the extent the disclosure is authorized by
statute or regulation in the exercise of professional judgement
the doctor believes the disclosure is necessary to prevent
serious harm to the individual or other potential victim.
OVERSIGHT AGENCIES
Federal law allows us to release your protected health information
to appropriate health oversight agencies or for health oversight
activities to include audits, civil, administrative or criminal
investigations, inspections, licensures or disciplinary actions,
and for similar reasons related to the administration of healthcare.
JUDICIAL/ADMINISTRATIVE PROCEEDINGS
We may disclose your protected health information in the course
of any judicial or administrative proceeding as allowed or
required by law, or as directed by a proper court order or
administrative tribunal, provided that only the protected
health information released is expressly authorized by such
order, or in response to a subpoena, discovery request or
other lawful process.
LAW ENFORCEMENT
We may disclose our protected health information for law enforcement
purposes as required by law, such as wen required by court
order, including laws that require reporting of certain types
of wounds or other physical injury.
CORONERS, MEDICAL EXAMINERS AND
FUNERAL DIRECTORS
We may disclose your protected health information to funeral
directors or coroners consistent with applicable law to allow
them to carry out their duties.
ORGAN PROCUREMENT ORGANIZATIONS
Consistent with applicable law, we may disclose your protected
health information to organ procurement organizations or other
entities engaged in the procurement, banking, or transplantation
of organs or eyes, for the purpose of donation and transplant.
RESEARCH
We may disclose information to researchers when an institutional
review board that has reviewed the research proposal and established
protocols to ensure the privacy of your protected health information
has approved their research.
THREAT TO HEALTH AND SAFETY
To avert a serious threat to health or safety, we may disclose
your protected health information consistent with applicable
law to prevent or lessen a serious, imminent threat to the
health or safety of a person or the public.
FOR SPECIALIZED GOVERNMENTAL
FUNCTIONS
We may disclose your protected health information for specialized
government functions as authorized by law such as to Armed
Forces personnel, for national security purposes, or the public
assistance program personnel.
CORRECTIONAL INSTITUTIONS
If you are an inmate of a correctional institution, we may
disclose to the institution or it’s agents the protected
health information necessary for your health and the health
and safety of other individuals.
WORKERS COMPENSATION
If you are seeking compensation through Workers Compensation,
we may disclose your protected health information to the extent
necessary to comply with laws relating to Workers Compensation.
OTHER USE AND DISCLOSURES
Other uses and disclosures besides those identified in this
Notice will be made only as otherwise authorized by law or
with your written authorization which you may revoke except
to the extent information or action has already been taken.
Website
We maintain a website that provides information about our
entity and a summary of this Notice will be listed on the
website.
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