Pediatric Health Care of North Georgia PC
400 Dawson Commons / Suite 200 / Dawsonville, GA 30534
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU MAY OBTAIN ACCESS
TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY
Effective Date: 2/1/2008
If you have any questions about this notice, please contact the Pediatric Health Care of North Georgia, P.C. Privacy Officer at 706 429-9965
WHO WILL FOLLOW THIS NOTICE
This notice describes the practices of:
· Pediatric Health Care of North Georgia, P.C. (“Practice”).
· Any health care professional authorized to enter information into your medical record maintained by Practice
· All departments and units of Practice that have access to your medical record.
· Any medical professionals covering call for Practice physicians or staff while you are a patient of Practice.
· All these persons, entities, sites, and locations follow the terms of this notice. In addition, these persons, entities, sites, and locations may share medical information with each other for treatment, payment, or health care operations purposes as described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive from Practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated or maintained by Practice, whether made by Practice personnel or other health care providers. Other health care providers may have different policies or notices regarding their use and disclosure of your medical information.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your medical information.
We are required by law to:
· Make sure that medical information that identifies you is kept private;
· Give you this notice of our legal duties and privacy practices, and your legal rights, with respect to medical information about you; and
· Follow the terms of the notice that is currently in effect
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
If you do not give your consent for Practice to use and disclose your medical information as outlined in this Notice, we will only use and disclose your medical information in the following circumstances:
· To providers employed by or under contract with Practice who are personally involved in providing care pursuant to your consent to treatment (whether such consent is express, implied by law, or through substituted consent as authorized by law), but only during the period of time they are providing care to you;
· To bill you for the charges you incurred while you were a patient of Practice;
· To third parties when required by law or by appropriate legal process issued by a court or governmental agency with jurisdiction;
· If you area Medicare, Medicaid, CHAMPUS/TriCare, or other federal or state program beneficiary or enrollee, for treatment and payment purposes as outlined in this Notice;
· In the case of an emergency, when are transferring you to a receiving facility for care; and
· In the case of an emergency, in order to provide you with care that is required by federal and state law.
Should you give your consent; we will use and disclose your medical information as outlined in this Notice. The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples.
Ø For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, volunteers, or other personnel who are involved in taking care of you at Practice. We also may disclose medical information about you to people outside Practice who are involved in your medical care after you have been treated by Practice, such as family members or employees or medical staff members of any hospital or skilled nursing facility to which you are transferred or subsequently admitted.
Ø For Payment: We may use and disclose medical information about you so that the treatment and services you receive from Practice may be billed to and payment may be collected from you, and insurance company, or a third party. For example, we may need to give your health plan information about treatment you received from Practice so your health plan will pay us or reimburse you for the treatment. We also may disclose information about you to another health care provider, such as a hospital or other facility to which you are admitted, for their payment activities concerning you.
Ø For Health Care Operations: We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run Practice and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services Practice should offer, and what services are not needed. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other health care providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning the identities of specific patients. We also may disclose information about you for another health care provider’s health care operations if you also have received care from that provider, and we also may disclose information about you for the health care operations of other providers for use in their health care operations.
Ø Release to the Media: Unless you tell us otherwise, we may include certain limited information about you in press releases to the media. This information may include your name and your general condition (e.g., fair, stable, etc.). If you do not want anyone to know this information about you, if you want to limit the amount of information that is disclosed, or if you want to limit who gets this information, you must notify Practice’s Privacy Officer in writing.
Ø Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. This would include persons named in any durable health care power of attorney or similar document provided to us. We may also give information to someone who helps pay for some or all of your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. You can object to these releases by telling us that you do not wish any or all individuals involved in your care to receive this information. If you are not present or cannot agree or object, we will use our professional judgment to decide whether it is in your best interest to release relevant information to someone who is involved in your care or to an entity assisting in a disaster relief effort.
Ø As Required by Law. We will disclose medical information about you when required to do so by federal, state, or local law.
Ø To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Ø Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation, or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.
Ø Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. We may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits
Ø Workers’ compensation. We may release medical information about you for Workers’ Compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Ø Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
o To prevent or control disease, injury, or disability;
o To report deaths;
o To report reactions to medications or problems with products; to notify people of recalls of products they may be using;
o 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; and
o 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 by law.
Ø Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Ø Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Ø Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
o In response to a court order, warrant, summons, or similar process;
o To identify or locate a suspect, fugitive, material witness, or missing person;
o About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement.
o About a death we believe may be the result of criminal conduct;
o About criminal conduct at Practice facilities; and
o In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.
Ø Coroners and Medical Examiners. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
Ø National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Ø Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.
Ø Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical 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; (3) for the safety and security of the correctional institution; or (4) to obtain payment for services provided to you.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:
Ø Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes and other mental health records under certain circumstances
To inspect and copy medical information that may be sued to make decisions about you, you must submit your request in writing to Practice’s Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.
We may deny your request to inspect and copy your medical information in certain very limited circumstances, such as when the Practice Medical Director determines that for medical reasons this is not advisable. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will do what this person decides.
Ø Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request and amendment for as long as the information is kept by or for Practice.
To request an amendment, your request must be made in writing and submitted to Practice’s Privacy Officer. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
· Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
· Is not part of the medical information kept by or for Practice;
· Is not part of the information which you would be permitted to inspect and copy; or
· We have determined the information to be accurate and complete
Ø Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we have made of medical information about you.
To request this list or accounting of disclosures, you must submit your request in writing to Practice’s Privacy Officer and state whether you want the list on paper or electronically. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred. We may collect the fee before providing the list to you.
Ø Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limitation on the medical information we disclosed about you to someone who is involved in your care or the payment of your care like a family member or friend.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
To request restrictions, you must make your request in writing to Practice’s Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Ø Right to Request How we Communicate With You. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, or at another mailing address besides your home address. We must accommodate your request, if it is reasonable. You are not required to provide us with an explanation as to the reason for your request. Contact the Privacy Officer if you require such confidential communications.
Ø Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice, request a copy from Practice’s Privacy Officer in writing.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in Practice’s reception area. The notice will contain on the first page, in the top right-hand corner, the effective date. If the notice changes, a copy will be available to you upon request.
If you believe your privacy rights have been violated, you may file a complaint with Practice or with the Secretary of the United States Department of Health and Human Services. To file a complaint with Practice or for more information, contact Allison O’Shields, Practice’s Privacy Officer, by telephone at 706 429-9965, by mail at 400 Dawson Commons / Suite 420 / Dawsonville, GA 30534.
All complaints must be submitted in writing. You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice will be made only with your written permission or as required by law. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. Your revocation will be effective as of the end of the day on which you provide it in writing to Practice’s Privacy Officer. If you revoke your permission, we will no longer use or disclose medical information about you for the purpose that you had authorized in writing. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.