THIS NOTICE OF PRIVACY PRACTICES CONTAINS INFORMATION REQUIRED BY LAW about how D&J Medical may use and disclose your Protected Health Information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights with respect to your protected health information. Your “protected health information” means any health information, including demographic data that can be used to identify you, that is created or received by D&J Medical, and that relates to your past, present or future physical or mental health or condition.
1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
A. Uses and Disclosures of Protected Health Information with your Consent
D&J Medical may request your consent to use and disclose your Protected Health Information for the purpose of providing health care services to you. Your Protected Health Information may also be used and disclosed to pay your health care bills, for the health care operations of this facility, and as follows:
For Treatment: We will use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related treatment. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. We will also disclose Protected Health Information to other health care providers involved in your care. For example, we would disclose your protected health information, as necessary, to the physician that referred you to us.
For Payment: Your Protected Health Information will be used, as needed, to obtain payment for your health care services. This may include our submission of claims for payment and other activities that your health insurance plan may require before it approves or pays for the health care services we recommend for you, such as: making a determination of eligibility or coverage for insurance benefits, obtaining prior approval or authorization for treatment, and reviewing services provided to you for medical necessity.
For Healthcare Operations: We may use or disclose, as needed, your Protected Health Information to support the business and accreditation activities of D&J Medical. These activities may include, but are not limited to quality assessments, employee reviews, legal services, licensing, and conducting or arranging for other business activities.
For Business Associates: We may share your Protected Health Information with third party business associates who perform various activities (e.g., billing, transcription services) for this Facility. Whenever Business Associates receive your Protected Health
Information, they will have to enter into a written contract that contains terms that will protect the privacy of your Protected Health Information.
Treatment Alternatives: We may use or disclose your Protected Health Information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Appointment Reminders: We may use or disclose your Protected Health Information, as necessary, to contact you to remind you of your appointment.
Sign-In Sheets: We may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when your fitter, orthotist or prosthetist is ready to see you.
B. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke your authorization, at any time, in writing. You understand that we can not take back any use or disclosure we may have made under the authorization before we received your written revocation, and that we are required to maintain a record of the medical care that has been provided to you. The PHI authorization is a separate document, and you will have the opportunity to review any authorization before you sign it. We will not condition your treatment in any way on whether or not you sign any authorization.
C. Other Permitted and Required Uses and Disclosures That May Be Made Either With Your Agreement or the Opportunity to Object
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, orally or in writing, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose your Protected Health Information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location or general condition.
D. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your Protected Health Information in the following situations without your authorization or without providing you with the opportunity to object.
Required By Law: We may use or disclose your Protected Health Information to the extent that the use or disclosure is required by federal, state or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your Protected Health Information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. A disclosure under this exception would only be made to someone in a position to help prevent the threat to public health.
Communicable Diseases: We may disclose your Protected Health Information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose Protected Health Information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, and other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your Protected Health Information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your Protected Health Information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. We will only make this disclosure if you agree or when required or authorized by law. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Military and Veterans: If you are a member of the military, we may release Protected Health Information about you as required by military command authorities.
Food and Drug Administration: We may disclose your Protected Health Information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose your Protected Health Information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal and in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may disclose your Protected Health Information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes might include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the facility’s premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose your Protected Health Information to a coroner or medical examiner for identification purposes, determining cause of death or to perform other duties authorized by law. We may also disclose Protected Health Information to a funeral director, to carry out his/her duties. Protected Health Information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: Under certain circumstances, we may disclose your Protected Health Information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your Protected Health Information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your Protected Health Information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose your Protected Health Information if you are in the Armed Forces (1) for activities deemed necessary by appropriate military command authorities; (2) for determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military service. We may also disclose your Protected Health Information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation: We may disclose your Protected Health Information to comply with workers’ compensation laws and other similar legally-established programs that provide benefits for work-related illnesses and injuries.
Inmates: We may use or disclose your Protected Health Information if you are an inmate of a correctional facility and your fitter, orthotist or prosthetist created or received your Protected Health Information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
2. YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
Following is a statement of your rights with respect to your Protected Health Information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your Protected Health Information. To inspect and copy your medical information, you must submit a written request to us. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request. We may deny your request in limited situations specified in the law.
You have the right to request additional restrictions of your Protected Health Information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your Protected Health Information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
D&J Medical is not required to agree to a restriction that you may request.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location and we may accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing.
You may have the right to request an amendment of your Protected Health Information. We are not obligated to honor your request.
You have the right to receive an accounting of certain disclosures we have made, if any, of your Protected Health Information. Your right to receive this information is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of our current Notice from us, even if you have agreed to accept this notice electronically. You may obtain a copy of this notice at any of our offices and on our website, www.dandjmedical.com.
If you believe your privacy rights have been violated, you may complain to us or to the Secretary of Health and Human Services. You also may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you in any way for filing a complaint, either with us or with the Secretary. You may contact our Privacy Officer, Cynthia Wursta, at 2823 Orchard Lakes Drive, Baldwin, MD 21013, telephone (410) 692-7990, fax (410) 692-7969 or email@example.com for further information about the complaint process.
4. CHANGES TO THIS NOTICE
We reserve the right to change the privacy practices that are described in this Notice of Privacy Practices. We also reserve the right to apply these changes retroactively to Protected Health Information received before the change in privacy practices. You may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, requesting the current notice at the time of your next appointment, or accessing our website.