HIPAA Notice

Notice of Privacy Practices For Southwestern Medical Clinic

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 COMMITMENT TO YOUR PRIVACY

This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice describes how we may use and disclose your protected health information 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 to access and control your protected health information in some cases. Your "protected health information" means any of your written and oral health information, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and relates to your past, present or future physical or mental health or condition.

To summarize, this Notice provides you with the following important information:

How we may use and disclose your identifiable health information
Your privacy rights in your identifiable health information
Our obligation concerning the use and disclosure of your protected health information
The terms of this Notice apply to all records containing your identifiable health information that are created or retained by our practice. We reserve the right to amend our Notice of Privacy Practices. Any revision or amendment to this Notice will be effective for all of your records our practice has created or maintained in the past, and for any of your records we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a prominent location, and you may request a copy of our most current Notice during any office visit.

If you have questions about this privacy notice contact the Privacy Officer at (269) 983-8195.

WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS

Our practice may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless our practice has obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA Privacy Regulation or State law. Disclosures of your protected health information for the purposes described in this Notice may be made in writing, orally, or by facsimile.

For Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party for treatment purposes. For example, we may disclose your protected health information to a pharmacy to fulfill a prescription, to a laboratory to order a blood test, or to a home health agency that is providing care in your home. We may also disclose protected health information to other physicians who may be treating you or consulting with your physician with respect to your care. Additionally, we may disclose your protected health information to others who may assist in your care, such as your spouse, children, or parents.

For Payment. Our practice may use and disclose your protected health information 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 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 protected health information to obtain payment from third parties that may be responsible for such costs, such as family members. We may use your protected health information to bill you directly for services and items. Also, we may disclose your protected health information to another provider involved in your care for the other provider's payment activities.

For Operations. We may use or disclose your protected health information, as necessary, for our own health care operations in order to facilitate the function of the practice and to provide quality care to all patients. Health care operations include such activities as:

Quality assessment and improvement activities
Training programs including those in which students, trainees, or practitioners in healthcare learn under supervision
Review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs
Business planning activities
Appointment Reminders. We may use and disclose your protected health information to contact you and remind you of an appointment.
Treatment Options. We may use and disclose your protected health information to inform you of potential treatment options or alternatives.
Health-Related Benefits and Services. We may use and disclose your protected health information to inform you of health-related benefits or services that may be of interest to you.

USES AND DISCLOSURES BEYOND TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS PERMITTED WITHOUT AUTHORIZATION OR OPPORTUNITY TO OBJECT

Federal privacy rules allow us to use or disclose your protected health information without your permission or authorization for a number of reasons including the following:

Disclosures Required by Law. We will disclose your protected health information when we are required to do so by any Federal, State or local law.

Public Health Risks. We will disclose your protected health information to public health authorities that are authorized by law to collect information for the purpose of:

Maintaining vital records, such as births and deaths
Reporting child abuse or neglect
Preventing or controlling disease, injury or disability
Notifying a person regarding potential exposure to a communicable disease
Notifying a person regarding a potential risk for spreading or contracting a disease or condition
Reporting reactions to drugs or problems with products or devices
Notifying individuals if a product or device they may be using has been recalled
Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
Notify your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance
Health Oversight Activities: Our practice may disclose your protected health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and health care system in general.

Lawsuits and Similar Proceedings: Our practice may use and disclose your protected health information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your protected health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

Law Enforcement Purposes: We may disclose your protected health information to a law enforcement official for law enforcement purpose as follows:

As required by law for reporting of certain types of wounds or other physical injuries
Pursuant to court order, court-ordered warrant, subpoena, summons or similar process
For the purpose of identifying or locating a suspect, fugitive, material witness or missing person
Under certain limited circumstances, when you are the victim of a crime
To a law enforcement official if the practice has a suspicion that your death was the result of criminal conduct
In an emergency in order to report a crime
Coroners, Funeral Directors, and for Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research Purposes: We may use or disclose your protected health information for research when the use or disclosure for research has been approved by an institutional review board or privacy board that has reviewed the research proposal and research protocols to address the privacy of your protected health information.

In the Event of a Serious Threat To Health Or Safety: We may, consistent with applicable law and ethical standards of conduct, use or disclose your protected health information if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

Specified Government Functions: In certain circumstances, the Federal regulations authorize the practice to use or disclose your protected health information to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.

Inmates: Our practice may disclose your protected health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

Workers' Compensation: Our practice may release your protected health information for workers' compensation and similar programs.

USES AND DISCLOSURES WHICH YOU AUTHORIZE

Other than as stated above, we will not disclose your protected heath information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

You have the following rights regarding your health information.

The right to inspect and copy your protected health information: You have the right to inspect and obtain a copy of the protected health information that may be used to make decisions about you, including patient medical records and billing records.

Under Federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.

We may deny your request to inspect or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.

To inspect and copy your medical information, you must submit a written request to an office coordinator or the Privacy Officer, whose contact information is listed on the last page of this Notice. 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. Please contact our Privacy Officer if you have questions about access to your medical record.

The right to request a restriction on uses and disclosures of your protected health information. You may ask us not to use or disclose certain parts of your protected health information for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specified restriction requested and to whom you want the restriction to apply.

We are not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If the practice does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting our Privacy Officer.

The right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may 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 require you to provide an explanation for your request. Requests must be made in writing to our Privacy Officer.

The right to have your physician amend your protected health information. You may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be in writing and must be directed to our Privacy Officer. In this written request, you must also provide a reason to support the requested amendment.

The right to receive an accounting of disclosures. You have the right to request an accounting of certain disclosures of your protected health information made by our practice. An "accounting of disclosures" is a list of certain disclosures our practice has made of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. We are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

The right to obtain a paper copy of this notice. Upon request, we will provide a separate paper copy of this notice even if you have already received a copy of the notice or have agreed to accept this notice electronically.

The right to provide authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your protected health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your protected health information for the reasons described in the authorization. Please note, we are required to retain records of your care.

OUR DUTIES

Our practice is required by law to maintain the privacy of your health information and to provide you with this Notice of our duties and privacy practices. We are required to abide by the terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all protected health information that we maintain. We will re-distribute our Notice if changes are made and you may ask us to give you a copy of this Notice at anytime.

COMPLAINTS

You have the right to make a complaint to our practice and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may make a complaint to our practice by contacting the Privacy Officer in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

CONTACT PERSON

Our practice's contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer at: (269) 983-8195.

Notice #41403