HIPPA Privacy Policy

Notice Of Privacy Practices For Protected Health Information Alternate Translation

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

 


 

Understanding Your Medical Record Information

Each time you visit a hospital, doctor, or other health care provider, a record of your visit is made. Typically, this record will contain information about your symptoms, results of your physical examination and diagnostic tests, an assessment of your current medical condition and a plan for future care or treatment. This information, often referred to as your health or medical record, is considered "protected health information" (PHI) and serves as a basis for planning and documenting your care and treatment and provides a means of communication among the many health care professionals who contribute to your care.

The medical record is also a legal document that describes the care you received and is the means by which you, or your insurance carrier, can verify that the services billed were actually provided. The medical record can also serve as a tool in educating health professionals and can provide a valuable source of data for medical research and quality improvement initiatives. The medical record may also be utilized by public health officials charged with improving the overall health of the community. Additionally, the medical record may be used as a source of data for facility planning and marketing.

Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information and make more informed decisions when authorizing disclosure of that information to others.

 

Examples Of Uses And Disclosures Of Phi For Treatment, Payment, And Health Care Operations (TPO)

Your Family Doctor requests that you sign a one-time General Consent for Treatment form which allows the organization, including Your Family Doctor Clinic's Prescription Pharmacy, to use or disclose your health information for purposes relating to treatment, payment or health care operations, as outlined below:

We will use your health information for treatment. For example: Information obtained by a nurse, physician, health educator, or other member of your health care team will be recorded in your medical record and will be used to determine the appropriate course of treatment for your particular medical problems or concerns. Your medical record at Your Family Doctor will contain entries from all of the different providers that you have seen at Your Family Doctor to ensure that there is continuity in your care.

Additionally, your record may also contain copies of results from tests performed at Your Family Doctor (e.g. laboratory and radiology studies) and correspondence from other health care professionals who have been treating you outside of Your Family Doctor (as long as you have authorized those providers to send information to Your Family Doctor. As a result, your physician will have an accurate and complete picture of your medical condition and will be better able to safely treat your medical problems.

We will use your health information for payment. For example: Following your treatment, a bill for services rendered is sent to you or to a third party payer (insurance company). The information on the bill may include information that identifies you, as well as your diagnosis, any procedures that were performed, and any medications or supplies used.

We will use your health information for regular health care operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your medical record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and services we provide.
  • Business associates: There are some services provided in our organization through contracts with business associates. Examples include copy services we use when making copies of your health record, transcription services we use to transcribe physicians' notes, or consultants we may hire to assist us in various aspects of health care administration. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information and they are contractually obligated to do so.
  • Notification, Reminders: We may contact you by mail or phone to remind you about an upcoming appointment or to inform you about test results.
  • Communication with family: Using their best judgment, health care professionals may disclose health information to your family member, close personal friend, or any other person you identify as involved in your care or payment related to your care. However, you have the right to choose to whom we disclose this information.
  • Research: We may disclose information to researchers when an institutional review board (IRB) or "privacy board" that has reviewed the research proposal, and established protocols to ensure the privacy and confidentiality of your health information, has approved the research. Furthermore, Your Family Doctor is permitted to use or disclose PHI recorded or received for research prior to April 14, 2003, provided there exists on file an express legal permission or an informed consent from you or your representative.
  • Funeral directors: We may disclose health information to funeral directors consistent with applicable law in order to assist them to carry out their duties.
  • Marketing: We may contact you to provide information about treatment alternatives, new medications or other health-related benefits and services that may be of interest to you.
  • Fundraising: We may contact you as part of a fundraising effort.
  • Food and Drug Administration (FDA): We may disclose to the FDA any health information that relates to unusual or adverse events in connection with medications, supplements, or health care equipment in order to facilitate medication and/or equipment recalls.
  • Workers compensation: We may disclose 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.
  • Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Such information may include, but is not limited to, the reporting of abuse or neglect, the reporting of communicable diseases, and the reporting of reactions to medications or problems with products or devices.
  • Health oversight activities: We may disclose your health information to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, audits, surveys, licensure and disciplinary actions, criminal procedures or actions, or other activities necessary for the government to monitor programs, compliance with civil rights laws, and the health care system in general.
  • Law enforcement: We may disclose your health information if asked to do so by a law enforcement official or in response to a valid subpoena, search warrant, court order or other similar legal process. For example, we may release your health information, if asked to do so by law enforcement officials, in the following circumstances: a suspicion of criminal conduct or a death potentially resulting from criminal conduct or in response to a warrant, summons, court order, subpoena or other similar legal process.
 

Authorizations

You may be asked to sign an authorization when Your Family Doctor is requesting permission to use your protected health information for purposes other than treatment, payment or health care operations, or to disclose this information to a third party for purposes not outlined above in Section II.

Examples include: disclosing information to an employer for employment decisions, or disclosing information for eligibility for life insurance. Additionally, an authorization will be required to use or disclose psychotherapy notes for treatment by persons other than the originator of the notes.

 

Your Health Information Rights

Although your medical record is the physical property of Your Family Doctor, the information that it contains belongs to you. As a result, you have the following rights regarding the health information that we maintain about you:
  • You have the right to obtain a paper copy of our Notice of Privacy Practices for Protected Health Information upon request. Upon signing the General Consent for Treatment form at registration, you are provided a copy of this Notice to read and take home with you. A copy of this Notice is also posted at all Your Family Doctor locations and on our website, yourfamilydoctor.org. Even if you have obtained this Notice in another form, or at another time, you are still entitled to a paper copy of this Notice upon request.
  • You have the right to inspect a copy of your medical record. You have the right to inspect medical information that may be used to make decisions about your care. This includes medical and billing records but may exclude certain mental health information (e.g., psychotherapy notes). To view your medical record in person, you must submit a request in writing to the Your Family Doctor Health Information Services (HIS) Department (Attention: Release of Information/ Correspondence), 1280 Hwy 74 S., Suite 100, Peachtree City, GA 30269. You will obtain a response regarding your request within 5 business days, after which you may come to the Correspondence Office to inspect your records in person. In some limited circumstances, your provider may deny your request to inspect your medical record and you would be notified of this denial in writing with an explanation of the basis for the denial. In such cases, you may request that your denial be reviewed. Another licensed health care professional chosen by Your Family Doctor will review both your request and the denial. Your Family Doctor will be bound by the outcome of this secondary review.
  • You have the right to obtain a copy of your medical record. You may request a copy of your medical record by submitting an Authorization to Release Medical Information form to the Your Family Doctor Health Information Services (HIS) Department (Attention: Release of Information/ Correspondence), 1280 Hwy 74 S., Suite 100, Peachtree City, GA 30269. There are fees involved in providing you a paper-based copy for your personal use depending on how you would like your record delivered to you. However, there are no charges involved if the copy is to go directly from the ROI/ Correspondence Office to your physician or other health care provider. Your request will be processed within 15 business days, and you will be notified as soon as your copy is ready. As outlined above, a request to obtain a copy of certain mental health information may be denied by your provider and you will be notified regarding that denial within 5 business days from receipt of your request.
  • You also have the right to make an addendum or request an amendment to the information in your health record. If you believe that medical information we have about you is incorrect or incomplete, you may provide us a written addendum to any item or statement in your medical record or you may ask us to amend the information. To file a written addendum, you must fill out a Request to File an Addendum to Protected Health Information form. To request an amendment, you must complete a Request to Amend Protected Health Information form. The applicable form can be submitted by mail, by fax (770-692-0845), or in person to the Your Family Doctor HIS Department, (Attention: ROI/ Correspondence), 1280 Hwy 74 S., Suite 100, Peachtree City, GA 30269. Be sure to include your reason for requesting the addendum or amendment. If your request is not in writing or does not state any reason to support your request, we may have to deny it. In addition, we may deny your request if you ask us to change information that:
    • Was not originated by Your Family Doctor, unless the person or entity that generated the information is no longer available to make the amendment.
    • Is not part of the medical record (your PHI) kept by Your Family Doctor.
    • Is not part of the information which you would be permitted to inspect and/ or copy under Your Family Doctor policy.
    • Is accurate and complete as is.
    You will receive a response from the ROI/ Correspondence Office regarding your request within 15 days following receipt.
  • You have the right to revoke your authorization to use or disclose health information at any time except to the extent that the information has already been used or disclosed. For example, Your Family Doctor may obtain your written authorization to use or disclose your health information for purposes other than treatment, payment or health care operations (e.g., you may sign an authorization allowing Your Family Doctor to disclose your protected health information to a life insurance company in order to obtain life insurance coverage). Any authorization you provide to us regarding the use and/or disclosure of your health information may be revoked at any time. You must submit your request in writing to the Your Family Doctor HIS Department (Attention: ROI/ Correspondence Office), 1280 Hwy 74 S., Suite 100, Peachtree City, GA 30269. Your request shall be processed within 15 business days following receipt. After you revoke your authorization we will no longer use or disclose your health information for the purposes described in the authorization.
  • You have the right to obtain an "accounting of disclosures" of your health information. An accounting of disclosures is a list of certain non-routine disclosures that Your Family Doctor has made of your health information for purposes other than treatment, payment or health care operations and for which you did not sign an authorization form. Examples of non-routine disclosures include disclosures made to law enforcement or public health officials. In order to obtain an accounting of disclosures, you must obtain and complete a Request for an Accounting of Disclosures of Protected Health Information form available at every Your Family Doctor location. You may submit this form by mail, by fax (770-692-0845), or in person to the Your Family Doctor HIS Department, (Attention: ROI/ Correspondence Department), 1280 Hwy 74 S., Suite 100, Peachtree City, GA 30269. The request must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. Your request shall be processed within 30 days from receipt. The first list you request within a twelve-month period is free of charge, but Your Family Doctor will charge for additional lists within the same twelve-month period.
  • You have the right to request a restriction on certain uses and disclosures of your health information. You have the right to request a restriction or limitation on the medical information we use or disclose about you. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care, such as family members or friends. For example, you may ask that we not use or disclose information about a surgery or treatment that you had at Your Family Doctor to anyone other than your daughter. Your Family Doctor is 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 of Your Family Doctor's use or disclosure of your health information, you must obtain and complete a Request for Special Restriction on Use or Disclosure of Protected Health Information form and submit this form by mail, by fax (770-692-0845), or in person to the Your Family Doctor HIS Department, (Attention: ROI/ Correspondence Department), 1280 Hwy 74 S., Suite 100, Peachtree City, GA 30269. The request must describe (a) the information you wish restricted, (b) whether you are requesting to limit Your Family Doctor's use, disclosure or both, and (c) to whom you want the limits to apply. Your request shall be processed within 30 days from receipt.
  • You have the right to request that Your Family Doctor communicate with you about your health and related issues in a particular manner or at a certain location (e.g., you may ask that we contact you at home, rather than at work). In order to request a type of confidential communication, you must obtain and complete a Request for Restriction on the Manner/ Method of Confidential Communications form and submit it by mail, by fax (770-692-0845), or in person to the Your Family Doctor HIS Department, (Attention: ROI/ Correspondence Department), 1280 Hwy 74 S., Suite 100, Peachtree City, GA 30269. Your request should specify the requested method of contact, or the location where you wish to be contacted. Your Family Doctor will accommodate all reasonable requests. You do not need to give a reason for your request. However, your request must be clear and specific as to how, when and where you wish to be contacted. Your request shall be processed within 30 days from receipt.
 

Our Responsibilities

Your Family Doctor is required to maintain the privacy of your health information and must provide you with a notice as to our legal duties and privacy practices with respect to the information we collect and maintain about you. Your Family Doctor must abide by the terms of this Notice and must notify you if we are unable to agree to a requested restriction. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain.

We will not use or disclose your health information without your authorization, except as described in this notice. Should our information practices change, we will post a revised Notice of Privacy Practices for Protected Health Information and it shall be made available upon request.

 

For More Information, To Report A Problem Or To File A Complaint

If you have questions and would like additional information, you may contact the Director of Health Information Services at (770) 631-1344 or Fax No. (770) 692-0845.

If you believe your privacy rights have been violated, you can file a written complaint with the Your Family Doctor Privacy Officer at 1280 Hwy 74 S., Suite 100, Peachtree City, GA 30269.

Additionally, you may file a complaint with the Secretary of Health and Human Services or with the U.S. Office of Civil Rights. There will be no retaliation for filing a complaint.

EFFECTIVE DATE: April 14, 2003