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Effective date: September 22, 2003 Ammended: September 30, 2008
THE DERMATOLOGY CLINIC, PLLC
Notice of
Privacy Practices
As required by
the privacy regulations created as a result of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
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This notice describes how health
information about you (as a patient of this practice) may be used and
disclosed and how you can get access to your individually identifiable
health information.
Please review this notice carefully.
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A. Our commitment to your privacy:
Our practice
is dedicated to maintaining the privacy of your individually identifiable
health information (also called protected
health information, or PHI). In conducting our business, we will create
records regarding you and the treatment and services we provide to you. We
are required by law to maintain the confidentiality of health information
that identifies you. We also are required by law to provide you with this
notice of our legal duties and the privacy practices that we maintain in
our practice concerning your PHI. By federal and state law, we must follow
the terms of the Notice of Privacy Practices that we have in effect at the
time.
We realize
that these laws are complicated, but we must provide you with the following
important information:
• How
we may use and disclose your PHI,
• Your
privacy rights in your PHI,
• Our
obligations concerning the use and disclosure of your PHI.
The terms of this notice apply to all
records containing your PHI that are created or retained by our practice.
We reserve the right to revise or amend this Notice of Privacy Practices.
Any revision or amendment to this notice will be effective for all of your
records that our practice has created or maintained in the past, and for
any of your records that we may create or maintain in the future. Our
practice will post a copy of our current Notice in our offices in a visible
location at all times, and you may request a copy of our most current
Notice at any time.
B. If you have questions about this Notice, please contact: Office Manager/Privacy Officer, The Dermatology
Clinic, PLLC. 11295 East Taylor Road, Gulfport, MS 39503, or you may call 228-864-3300.
C. We may use and disclose your PHI in
the following ways:
The following
categories describe the different ways in which we may use and disclose
your PHI.
1. Treatment. Our practice may use your PHI to
treat you. For example, we may ask you to have laboratory tests (such as
blood or urine tests), and we may use the results to help us reach a
diagnosis. We might use your PHI in order to write a prescription for you,
or we might disclose your PHI to a pharmacy when we order a prescription
for you. Many of the people who work for our practice – including, but not
limited to, our doctors and nurses – may use or disclose your PHI in order
to treat you or to assist others in your treatment. Additionally, we may
disclose your PHI to others who may assist in your care, such as your
spouse, children or parents. Finally, we may also disclose your PHI to
other health care providers for purposes related to your treatment.
2. Payment. Our practice may use and disclose
your PHI 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 PHI to obtain payment from
third parties that may be responsible for such costs, such as family
members. Also, we may use your PHI to bill you directly for services and
items. We may disclose your PHI to other health care providers and entities
to assist in their billing and collection efforts.
3. Health care operations. Our practice may use and disclose
your PHI to operate our business. As examples of the ways in which we may
use and disclose your information for our operations, our practice may use
your PHI 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 PHI to other health care providers and entities to
assist in their health care operations.
4. Appointment reminders. Our practice may use and disclose your
PHI to contact you and remind you of an appointment.
5. Treatment options. Our practice may use and disclose your
PHI to inform you of potential treatment options or alternatives.
6. Health-related benefits and
services. Our practice
may use and disclose your PHI to inform you of health-related benefits or
services that may be of interest to you.
7. Release of information to
family/friends. Our
practice may release your PHI to a friend or family member that is involved
in your care, or who assists in taking care of you. For example, a parent
or guardian may ask that a baby sitter take their child to the
pediatrician’s office for treatment of a cold. In this example, the baby sitter
may have access to this child’s medical information.
8. Disclosures required by law. Our practice will use and disclose
your PHI when we are required to do so by federal, state or local law.
D. Use and disclosure of your PHI in
certain special circumstances:
The following
categories describe unique scenarios in which we may use or disclose your
identifiable health information:
1. Public health risks. Our practice may disclose your PHI 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,
• Notifying
your employer under limited circumstances related primarily to workplace
injury or illness or medical surveillance.
2. Health oversight activities. Our practice may disclose your PHI 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 the health care system in general.
3. Lawsuits and similar proceedings. Our practice may use and disclose
your PHI in response to a court or administrative order, if you are
involved in a lawsuit or similar proceeding. We also may disclose your PHI
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.
4. Law enforcement. We may release PHI if asked to do so
by a law enforcement official:
• Regarding
a crime victim in certain situations, if we are unable to obtain the person’s
agreement,
• Concerning
a death we believe has resulted from criminal conduct,
• Regarding
criminal conduct at our offices,
• In
response to a warrant, summons, court order, subpoena or similar legal
process,
• To
identify/locate a suspect, material witness, fugitive or missing person,
• In an emergency, to report a crime (including the location
or victim(s) of the crime, or the description, identity or location of the
perpetrator).
5. Deceased patients. Our practice may release PHI to a
medical examiner or coroner to identify a deceased individual or to
identify the cause of death. If necessary, we also may release information
in order for funeral directors to perform their jobs.
6. Organ and tissue donation. Our practice may release your PHI to organizations
that handle organ, eye or tissue procurement or transplantation, including
organ donation banks, as necessary to facilitate organ or tissue donation
and transplantation if you are an organ donor.
7. Research. Our practice may use and disclose your
PHI for research purposes in certain limited circumstances. We will obtain
your written authorization to use your PHI for research purposes except when an Internal Review
Board or Privacy Board has determined that the waiver of your authorization
satisfies all of the following conditions:
(A) The use or disclosure involves no more
than a minimal risk to your privacy based on the following: (i) an adequate plan to protect the identifiers from
improper use and disclosure; (ii) an adequate plan to destroy the
identifiers at the earliest opportunity consistent with the research
(unless there is a health or research justification for retaining the
identifiers or such retention is otherwise required by law); and (iii)
adequate written assurances that the PHI will not be re-used or disclosed
to any other person or entity (except as required by law) for authorized
oversight of the research study, or for other research for which the use or
disclosure would otherwise be permitted;
(B) The research could not practicably be conducted without
the waiver,
(C) The research could not practicably be conducted without
access to and use of the PHI.
8. Serious threats to health or safety. Our practice may use and disclose
your PHI when necessary to reduce or prevent a serious threat to your
health and safety or the health and safety of another individual or the
public. Under these circumstances, we will only make disclosures to a
person or organization able to help prevent the threat.
9. Military. Our practice may disclose your PHI if
you are a member of U.S. or foreign military forces (including
veterans) and if required by the appropriate authorities.
10. National security. Our practice may disclose your PHI to
federal officials for intelligence and national security activities
authorized by law. We also may disclose your PHI to federal and national
security activities authorized by law. We also may disclose your PHI to
federal officials in order to protect the president, other officials or
foreign heads of state, or to conduct investigations.
11. Inmates. Our practice may disclose your PHI 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.
12. Workers’ compensation. Our practice may release your PHI for
workers’ compensation and similar programs.
E. Your rights regarding your PHI:
You have the
following rights regarding the PHI that we maintain about you:
1. Confidential communications. You have the right to request that
our practice communicate with you about your health and related issues in a
particular manner or at a certain location. For instance, you may ask that
we contact you at home, rather than work. In order to request a type of
confidential communication, you must make a written request to Office Manager/Privacy Officer, The Dermatology
Clinic, PLLC, 11295 East Taylor Road, Gulfport, MS 39503, specifying the requested method of
contact, or the location where you wish to be contacted. Our practice will
accommodate reasonable requests.
You do not need to give a reason for your request.
2. Requesting restrictions. You have the right to request a
restriction in our use or disclosure of your PHI for treatment, payment or
health care operations. Additionally, you have the right to request that we
restrict our disclosure of your PHI to only certain individuals involved in
your care or the payment for your care, such as family members and friends.
We are 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 in our use or disclosure of your PHI, you
must make your request in writing to Office Manager/Privacy Officer, The
Dermatology Clinic, PLLC, 11295
East Taylor Road, Gulfport, MS 39503. Your request must describe in a clear
and concise fashion:
• The
information you wish restricted,
• Whether
you are requesting to limit our practice’s use, disclosure or both,
• To
whom you want the limits to apply.
3. Inspection and copies. You have the right to inspect and
obtain a copy of the PHI that may be used to make decisions about you,
including patient medical records and billing records, but not including
psychotherapy notes. You must submit your request in writing to Office
Manager/Privacy Officer, The Dermatology Clinic, PLLC, 11295
East Taylor Road, Gulfport, MS 39503 in order to inspect and/or obtain a
copy of your PHI. Our practice may charge a fee for the costs of copying,
mailing, labor and supplies associated with your request. Our practice may
deny your request to inspect and/or copy in certain limited circumstances;
however, you may request a review of our denial. Another licensed health
care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health
information if you believe it is incorrect or incomplete, and you may
request an amendment for as long as the information is kept by or for our
practice. To request an amendment, your request must be made in writing and
submitted to Office Manager/Privacy Officer, The Dermatology Clinic, PLLC, 11295
East Taylor Road, Gulfport, MS 39503. You must provide us with a reason
that supports your request for amendment. Our practice will deny your
request if you fail to submit your request (and the reason supporting your
request) in writing. Also, we may deny your request if you ask us to amend
information that is in our opinion: (a) accurate and complete; (b) not part
of the PHI kept by or for the practice; (c) not part of the PHI which you
would be permitted to inspect and copy; or (d) not created by our practice,
unless the individual or entity that created the information is not
available to amend the information.
5. Accounting of disclosures. All of our patients have the right to
request an “accounting of disclosures.” An “accounting of disclosures” is a
list of certain non-routine disclosures our practice has made of your PHI
for purposes not related to treatment, payment or operations. Use of your
PHI as part of the routine patient care in our practice is not required to
be documented – for example, the doctor sharing information with the nurse;
or the billing department using your information to file your insurance
claim. In order to obtain an accounting of disclosures, you must submit
your request in writing to Office Manager/Privacy Officer, The
Dermatology Clinic, PLLC, 11295
East Taylor Road, Gulfport, MS 39503. All requests for an “accounting of
disclosures” 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. The
first list you request within a 12-month period is free of charge, but our
practice may charge you for additional lists within the same 12-month
period. Our practice will notify you of the costs involved with additional
requests, and you may withdraw your request before you incur any costs.
6. Right to a paper copy of this notice. You are entitled to receive a paper
copy of our notice of privacy practices. You may ask us to give you a copy
of this notice at any time. To obtain a paper copy of this notice, contact Office
Manager/Privacy Officer at 228-864-3300.
7. Right to file a complaint. If you believe your privacy rights
have been violated, you may file a complaint with our practice or with the
Secretary of the Department of Health and Human Services. To file a
complaint with our practice, contact Office Manager/Privacy Officer, The
Dermatology Clinic, PLLC, 11295
East Taylor Road, Gulfport, MS 39503. All complaints must be submitted in
writing. You will not be penalized
for filing a complaint.
8. Right to provide an 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 PHI may be revoked at any time in writing. After you revoke your authorization, we will no
longer use or disclose your PHI for the reasons described in the
authorization. Please note: we
are required to retain records of your care.
Again, if you
have any questions regarding this notice or our health information privacy
policies, please contact Office Manager/Privacy Officer at 228-864-3300.
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