THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We are required by law to maintain the privacy of "Protected health information”. (“PHI” abbreviation hereon in) “PHI" includes any identifiable information that we obtain from you or others that relate to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for health care provided to you.
As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we will make of your PHI. We must comply with the provisions of this notice, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all PHI we maintain. Copies of our most current privacy notice are available upon request from our office or you can access it on our website at www.medsourceinc.net.
PERMITTED USES AND DISCLOSURES
Once you give your written consent, we can use or disclose your PHI for purposes of treatment, payment and health care operations. If you refuse to consent, we do not have to provide you with non-emergency care. Treatment means the provision, coordination or management of your health care, including consultations between health care providers regarding your care and referrals for health care from one health care provider to another.
Payment means activities we undertake to obtain reimbursement for the health care provided to you, including determinations of eligibility and coverage and other utilization review activities. For example, prior to providing health care services, we may need to provide to your Health Insurance Company information about your medical condition to determine whether the proposed course of treatment will be covered. When we subsequently bill the Health Insurance Company for the services rendered to you, we can provide them with information regarding your care if necessary to obtain payment.
Health care operations means the support functions of our practice related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient inquiries or complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities
Even without your written consent or authorization, we can use or disclose PHI for purposes of treatment, payment and health care operations if:
- We have an indirect treatment relationship with you, that is, we provide health care to you based on the orders of another health care provider.
- You are a prison inmate at the time we created or received the protected health Information.
- You need emergency care and are incapable of giving consent, provided that we attempt to obtain your consent as soon as reasonably possible after the delivery of
- We are required by law to treat you, and our attempts to obtain your consent are unsuccessful; or
- We attempt to obtain your consent but cannot do so due to substantial barriers to communicating with you, and we determine that your consent to receive treatment
is clearly inferred from the circumstances.
OTHER USES AND DISCLOSURES
We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.
We may disclose your PHI to your family or friends or any other individual identified by you when they are involved in your care or the payment for your care. We will only disclose the PHI directly relevant to their involvement in your care or payment. We may also use or disclose your PHI to notify, or assist in the notification of, a family member, a personal representative, or another person responsible for your care of your location, general condition or death. If you are available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not available, we will determine whether a disclosure to your family or friends is in your best interest, and we will disclose only the PHI that is directly relevant to their involvement in your care. When permitted by law, we may coordinate our uses and disclosures of PHI with public or private entities authorized by law or by charter to assist in disaster relief efforts.
We will allow your family and friends to act on your behalf to pick up medical supplies, x-rays and similar forms of PHI, when we determine, in our professional judgment that it is in your best interest to make such disclosures.
Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement and or organ, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Work Related Injuries & Illnesses
If we provide health care to your for a work-related injury, we may release PHI about you to workers compensation or similar programs that provide benefits for purposes of work-related injuries or illness and permitted by state law.
Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by command authorities of the military.
Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following:
- to prevent or control disease, injury or disability;
- to report births and deaths;
- to report child abuse or neglect;
- to report reactions to medications or problems with products;
- to notify people of product, recalls, repairs of replacements;
- to notify a person who may have been exposed to a disease or may be
- at risk for contracting or spreading a disease or condition
- to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized
Health Oversight Activities:
We may disclose medical information to federal or state agencies that oversee our activities. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. We may disclose PHI to persons under the Food and Drug Administration's jurisdiction to track products or to conduct post-marketing surveillance.
We may disclose PHI pursuant to a valid court order, search warrant, and under certain circumstances, in response to a subpoena or other discovery request.
As required by law
We will disclose PHI when we are required to do so by federal or state law.
Serious Threats. As permitted by applicable law and standards of ethical conduct, we may use and disclose PHI if we, in good faith, believe that the use or disclosure is necessary to prevent or lesson a serious and imminent threat to the health or safety of a person or the public.
1. You have the right to request restrictions on our uses and disclosures of
PHI for treatment, payment and health care operations. However, we are
not required to agree to your request.
2. You have the right to reasonably request to receive communications of
PHI by alternative means or at alternative locations.
3 Subject to payment of a reasonable copying charge, you have the right to
inspect and copy the PHI contained in your medical and billing records
and in any other records used by us to make decisions about you, except
We may also deny a request for access to protected health information if:
- A licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger your life or physical safety or that of another person;
- The PHI makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other person; or
- The request for access is made by the individual's personal representative and a licensed health care professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to you or another person.
If we deny a request for access for any of the three reasons described above, then you have the right to have our denial reviewed in accordance with the requirements of applicable law.
4. You have the right to request a correction to your PHI, but we may deny
your request for correction, if we determine that the PHI or record that is
the subject of the request:
(i) was not created by us, unless you provide a reasonable basis to believe (ii) is not part of your medical or billing records; that the originator of PHI
is no longer available to act on the requested amendment;
(iii) is not available for inspection as set forth above; or
(iv) is accurate and complete.
In any event, any agreed upon correction will be included as an addition to, and not a replacement of, existing records,
5. You have the right to receive, an accounting of disclosures of PHI made
by us to individuals or entities other than to you, except for disclosures:
(i) to carry out treatment, payment and health care operations as provided
(ii) to persons involved in your care or for other notification purposes as
provided by law:
(iii) for national security or intelligence purposes as provided by law;
(iv) to correctional institutions or law enforcement officials as provided by
(v) that occurred prior to April 14, 2003.
6. You have the right to request and receive a paper copy of this notice
from us. You may request a paper copy at anytime.
Contact for information about this notice or to file a complaint about our privacy practices
If you have any questions about this notice, wish to exercise any of the rights explained in it or file a complaint about our privacy practices, feel that we may have violated your privacy rights or disagree with a decision we made about your PHI, please contact our office’s Compliance Officer, Simone Sirois, at (508)-646-4556 or firstname.lastname@example.org.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.
Effective date of this Notice
This notice is effective as of April 14, 2003 and supersedes any and all prior versions of this notice.