NORTHSIDE MEDICAL CLINIC, P.C.
31 HUGHES DRIVE - JACKSON, TN 38305
Notice of Privacy Practices for Protected Health
Information
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!
If you consent, the office is permitted
by federal privacy laws to make uses and disclosures of your health
information for purposes of treatment, payment, and health care
operations. Protected health information is the information we
create and obtain in providing our services to you. Such information
may include documenting your symptoms, examination and test results,
diagnosis, treatment, and applying for future care or treatment. It
also includes billing documents for those services.
Examples of uses of your health
information for treatment purposes are:
• A
nurse obtains treatment information about you and records it in a
health record.
• During
the course of your treatment, the physician determines he/she will
need to consult with another specialist in the area. He/she will
share the information with such specialist and obtain his/her input.
Example of use of your health
information for payment purposes:
• We
submit requests for payment to your health insurance company. The
health insurance company or business associate helping us obtain
payment requests information from us regarding our medical care
given. We will provide information to them about you and the care
given.
Example of Use of Your Information
for Health Care Operations:
•
We may obtain services
from business associates such as quality assessment, quality
improvement, outcome evaluation, protocol and clinical guidelines
development, training programs, credentialing, medical review,
legal services, and insurance. We will share information about you
with such business associates as necessary to obtain these
services.
YOUR HEALTH INFORMATION RIGHTS
The health and billing records we maintain are the physical property
of the doctor’s office. You have the following rights with respect
to your Protected Health Information.
1. Request
a restriction on certain uses and disclosures of your health
information by delivering the request in writing to our
office/hospital-we are not required to grant the request but we will
comply with any request granted;
2. Obtain
a paper copy of the Notice of Privacy Practices for Protected Health
Information by making a request at our office;
3. Right
to inspect and copy your health record and billing record-you may
exercise these rights by delivering the request in writing to our
office using the form we provide to you upon request; appeal a
denial of access to your protected health information except in
certain circumstances;
4. 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;
5. 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;
6. 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; and,
If you want to exercise any of the above
rights, please contact Sharron Pittman, Privacy Officer, 31
Hughes Drive, Jackson, TN 38305, in person or in writing,
during normal hours. She will provide you with assistance and the
steps to take to exercise your rights.
You have the right to review this Notice
before signing the consent authorizing use and disclosure of your
protected health information for treatment, payment, and health care
operations purposes.
Our Responsibilities
The office is required to:
• Maintain
the privacy of your health information as required by law;
• Provide
you with a notice as to our duties and privacy practices as to the
information we collect and maintain about you;
• Abide
by the terms of this Notice;
• Notify
you if we cannot accommodate a requested restriction or
request; and
• Accommodate
your request for an accounting of disclosures.
We reserve the right to amend, change,
or eliminate provisions in our privacy practices and access
practices and to enact new provisions regarding the protected health
information we maintain. If our information practices change, we
will amend our Notice. You are entitled to receive a revised copy of
the Notice by calling and requesting a copy of our “Notice” or by
visiting or office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like
additional information, or want to report a problem regarding the
handling of your information, you may contact Sharron Pittman,
Privacy Officer, 31 Hughes Drive, Jackson, TN 38305.
Additionally, if you believe your privacy
rights have been violated, you may file a written complaint at our
office by delivering the written complaint to Sharron Pittman,
Privacy Officer, 31 Hughes Drive, Jackson, TN 38305. You may
also file a complaint by mailing it or e-mailing it to the Secretary
of Health and Human Services whose street address and e-mail address
is Secretary Tommy G. Thompson, 200 Independence Avenue SW,
Washington, D.C. 20201 www.HHS.Mail@hhs.gov.
• We
cannot, and will not, require you to waive the right to file a
complaint with the Secretary of Health and Human Services (HHS) as a
condition of receiving treatment from the office.
• We
cannot, and will not, retaliate against you for filing a complaint
with the Secretary of Health and Human Services.
Following is a List of Other Uses and Disclosures Allowed by the
Privacy Rule
Patient Contact
We may contact you to provide you with
appointment reminders, with information about treatment alternatives,
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.
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 your death.
Communication with Family - Using our best
judgment, we may disclose to a family member, other relative, close
personal 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.
Opportunity to Agree or Object Not
Required
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.
Northside Medical Clinic, P.C. health
care providers working for an Industry performing medical surveillance
or evaluating whether the individual has a work related injury or
illness may disclose PHI pertaining to the work related injury or
illness to the employer if the employer needs the findings in order to
comply with OSHA regulations.
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 and 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 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, with your consent, 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 your protected health
information for law enforcement purposes as required by law, such as
when 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, eyes, or tissue for the purpose of
donation and transplant.
RESEARCH
We may disclose 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.
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
to 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 Uses 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
• If
we maintain a website that provides information about our entity, this
Notice will be on the website.
Effective Date: July 1, 2002
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