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.
We understand that your health information is personal
to you and we are committed to protecting the information about you. This Notice
of Privacy Practices (or “Notice”) describes how we will use and disclose protected
information and data that we receive or create related to your health care.
We are required by law to maintain the privacy of
your health information and to give you this Notice describing our legal duties
and privacy practices. We are also required to follow the terms of the Notice
currently in effect.
OF RECEIPT OF THIS NOTICE
You will be asked to provide a signed acknowledgement
of receipt of this notice. Our intent is to make you aware of the possible
uses and disclosures of your protected health information and your privacy rights.
The delivery of your health care services will in no way be conditioned upon
your signed acknowledgement. If you decline to provide a signed acknowledgement,
we will continue to provide your treatment, and will use and disclose your protected
health information for treatment, payment, and health care operations when necessary.
How We May
Use and Disclose Health Information About You
We will not use or
disclose your health information without your authorization except in the following
Treatment: We will use and disclose your
health information while providing, coordinating or managing your health care.
For example, information obtained by a nurse, physician or other member of your
health care team will be recorded in your record and used to determine the course
of treatment that should work best for you. Your physician will put in your
record his or her expectations of the members of your health care team. Members
of your health care team will then record the actions they took and their observations.
In that way, the physician will know how you are responding to treatment. We
may also provide other health care providers with your information to assist
him or her in treating you.
Examinations: We may disclose your health information
when authorized and necessary in response to requests made by Life, Casualty,
Workers’ Compensation or No Fault insurers, as well as judicial and administrative
proceedings such as court orders or subpoenas.
will use and disclose your medical information to obtain or provide compensation
or reimbursement for providing your health care. For example, we may send a
bill to you or your health plan. The information on or accompanying the bill
may include information that identifies you as well as your diagnosis, procedures
and supplies used. As another example, we may disclose information about you
to your health plan so that the health plan may determine your eligibility for
payment for certain benefits.
Health Care Operations: We
will use and disclose your health information to deal with certain administrative
aspects of your health care and to manage our business more efficiently. For
example, members of our medical staff may use information in your health record
to assess the quality of care and outcomes in your case and others like it.
This information will then be used in an effort to 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. We
may disclose your health information to our business associate so they can perform
the job we’ve asked them to do. However, we require the business associate
to take precautions to protect your health information.
Facility Director: Unless you notify us
that you object, we will use your name, location in the facility, general condition
(and religious affiliation) for directory purposes. This information may be
provided to members of the clergy and, except for religious affiliation, to
other people who ask for you by name.
Notification of Family: We
may use or disclose information to notify or assist in notifying a family member,
personal representative or other person responsible for your care, of your location
and general condition.
Communication With Family: 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.
with applicable law, 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 health information.
Funeral Director, Coroner and Medical Examiner:
Consistent with applicable law, we may disclose health information
to funeral directors, coroners and medical examiners to help them carry out
Organ Procurement Organizations: Consistent
with applicable law, we may disclose health information to organ procurement
organizations or other entities engaged in the procurement, banking or transplantation
of organs for the purpose of tissue donation and transplant.
may use certain information for purposes of raising funds.
Food and Drug Administration (FDA): We
may disclose to the FDA health information relative to adverse events, product
defects or post marketing surveillance information to enable product recalls,
repairs or replacement.
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 including child abuse and neglect.
Victims of Abuse,
Neglect or Domestic Violence: We may disclose your
health information to appropriate governmental agencies such as adult protective
or social services agencies if we reasonably believe you are a victim of abuse,
neglect or domestic violence.
Health Oversight: In
order to oversee the health care system, government benefits programs, entities
subject to governmental regulation and civil rights laws for which health information
is necessary to determine compliance, we may disclose your health information
for oversight activities authorized by law such as audits and civil, administrative
or criminal investigations.
Court Proceeding: We
may disclose your health information in response to requests made during judicial
and administrative proceedings such as court orders or subpoenas.
Law Enforcement: Under certain circumstances,
we may disclose your health information to law enforcement officials. These
circumstances include reporting required by certain laws (such as the reporting
of certain types of wounds), pursuant to certain subpoenas or court orders,
reporting limited information concerning identification and location at the
request of a law enforcement official, reports regarding suspected victims of
crimes at the request of a law enforcement official, reporting death, crimes
on our premises and crimes in emergencies.
Inmates: If you are an inmate
of a correctional institution or under the custody of a law enforcement official,
we may release health information about you to the correctional institution
or law enforcement official. This release would be necessary (1) for the institution
to provide you with health care; (2) to protect your health and safety or the
health and safety of others, or; (3) for the safety and security of the correctional
Threats to Public Health or Safety: We
may disclose or use health information when it is our good faith belief, consistent
with ethical and legal standards, that it is necessary to prevent or lessen
a serious and imminent threat or is necessary to identify or apprehend an individual.
Functions: Subject to certain requirements, we may
disclose or use health information for military personnel and veterans, for
national security and intelligence activities, for protective services for the
President and others, for medical suitability determinations for the Department
of State, for correctional institutions and other law enforcement custodial
situations and for government programs providing public benefits.
Workers’ Compensation: We
may disclose health information when authorized and necessary to comply with
laws relating to Workers’ Compensation or other similar programs.
Other Uses: We
may also use and disclose your personal health information for the following
- To contact
you to remind you of an appointment for treatment;
- To describe
or recommend treatment alternatives to you;
- To furnish
information about health related benefits and services that may be of interest
to you; or
- For certain
charitable fundraising purposes.
on Other Uses or Disclosures
We may not make any other use or disclosure of your
personal health information without your written authorization. Once given,
you may revoke the authorization by writing to the contact person listed below.
Understandably, we are unable to take back any disclosure we may have already
made with your permission.
You have many rights concerning the confidentiality
of your health information. You have the right:
- To request restrictions on the health
information we may use and disclose for treatment, payment and health care
operations. We are not required to agree to these requests. To request restrictions,
please send a written request to the address below.
- To receive confidential communications of health information about
you in a certain manner or at a certain location. For instance, you may request
that we only contact you at work or by mail. To make such a request, you must
write to us at the address below and tell us how or where you wish to be contacted.
- To inspect or copy your health information. You must submit your
request in writing to the address below. If you request a copy of your health
information, we may charge you a fee for the cost of copying, mailing or other
supplies. In certain circumstances, we may deny your request to inspect or
copy your health information. If you are denied access to your health information,
you may request that the denial be reviewed. Another licensed health care professional
will then review your request and the denial. The person conducting the review
will not be the person who denied your request. We will comply with the outcome
of the review.
- To amend health information. If you feel that the health information
we have about you is incorrect or incomplete, you may ask us to amend the information.
To request an amendment, you must write to us at the address below. You must
also give us a reason to support your request. We may deny your request to
amend your health information if it is not in writing or does not provide a
reason to support your request. We may also deny your request if:
- The information
was not created by us, unless the person that created the information is no longer available to make the amendment,
- The information is not part of the health information kept by or for us,
- Is not part of the information you would be permitted to inspect or copy, or
- Is accurate and complete.
- To receive an accounting of disclosures of your health information. You
must submit a request in writing to the address below. Not all health information
is subject to this request. Your request must state a time period, no longer
than 6 years and may not include dates before April 14, 2003. Your request
must state how you would like to receive the report (paper, electronically).
The first accounting you request within a 12-month period is free. For additional
accountings, we may charge you the cost of providing the accounting. We will
notify you of this cost and you may choose to withdraw or modify your request
before charges are incurred.
- To receive a paper copy of this Notice upon request, even if you have agreed
to receive the Notice electronically. You may also obtain a copy of this
notice at our website, www.drcarr.net.
You must submit a request for a paper notice in writing to the address below.
All requests to restrict
use of your health information for treatment, payment and health care operations
to inspect and copy health information, to amend your health information, or
to receive an accounting of disclosures of health information must be made in
writing to the contact person listed below.
If you believe that your privacy rights have
been violated, a complaint may be made to our privacy officer at
(315) 422-9233 or the address listed below. You
may also submit a complaint to the Secretary of the Department of Health and
Human Services. We will not retaliate against you for filing a complaint.
Our contact person
for all questions, requests or for further information related to the privacy
of your health information is:
Orthopedic Sports Medicine, P.C.
E. Genesee Street, Suite 201
We reserve the right to change our privacy practices
and to apply the revised practices to health information about you that we already
have. Any revision to our privacy practices will be described in a revised
Notice that will be posted primarily in our office.
Notice Effective Date: April 14, 2003