Please review this notice carefully. We are required by the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) to disclose how health
information about you, as a patient in our practice, may be used and disclosed.
Also, we must inform you of how you can get access to your individually identifiable
health information.
Our commitment to your privacy
Our practice is dedicated to maintaining the privacy of your individually
identifiable health information (IIHI). In conducting our business, we 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 are also 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 IIHI. 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 IIHI
Your privacy rights in your IIHI
Our obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your IIHI 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 must current Notice at any time.
If you have questions about this notice, please contact:
Vera Morgan, MA, Privacy Officer, 2665 North Decatur Road, Suite 325,
Decatur, Georgia 30033, telephone 404-292-5600, extension 11
Katherine Kirkpatrick, Office Manager, 2665 North Decatur Road, Suite
325, Decatur, Georgia 30033, telephone 404-292-5600, extension 14
We may use and disclose your Individually Identifiable Health Information
(IIHI) in the following ways:
Treatment: Our practice may use your IIHI 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 IIHI in order to write a prescription for you, or we might disclose
your IIHI 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 IIHI in order to treat you or to assist
others in your treatment. Additionally, we may disclose your IIHI to
others who may assist in your care, such as your spouse, children, or parents.
Finally, we may also disclose your IIHI to other health care providers for
purposes related to your treatment.
Payment: Our practice may use and disclose your IIHI 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 IIHI to obtain payment from
third parties that may be responsible for such costs, such as family members.
Also, we may use your IIHI to bill you directly for services and items.
We may disclose your IIHI to other health care providers and
entities to assist in their billing and collection efforts.
Health Care Operations: Our practice may use and disclose your
IIHI 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 IIHI to evaluate the quality of care your received
from us, or to conduct cost-management and business planning activities
for our practice. We may disclose your IIHI to other health care
providers and entities to assist in their health care operations.
Optional:
Appointment Reminders: Our practice may use and disclose your IIHI
to contact you and remind you of an appointment.
Treatment Options:
Our practice may use and disclose your IIHI to inform you
of potential treatment options or alternatives.
Health –Related Benefits and Services: Our practice may use
and disclose your IIHI to inform you of health-related benefits or
services that may be of interest to you.
Release of Information to Family/Friends: Our practice may release
your IIHI to a 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 babysitter take their child to the pediatrician’s office for treatment of a cold. In
this example, the babysitter may have access to this child’s
medical information.
Disclosure required by law: Our practice will use and disclose your IIHI
when we are required to do so by federal, state, or local law.
Use and disclosure of your IIHI in certain special
circumstances: the
following categories describe unique scenarios in which we may use
or disclose your IIHI
Public Health Risks: our practice may disclose your
IIHI 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 that 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
Health Oversight Activities: Our practice may disclose
your IIHI 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.
Lawsuits and Similar Proceedings: Our practice may
use or disclose your IIHI in response to a court or administrative
order, if you are involved in a lawsuit or similar proceeding.
We also may disclose your IIHI 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: We may release IIHI 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 of victim(s) of the crime, or the
description, identity or location of the perpetrator)
Optional:
Deceased patients: our practice may release IIHI to a medical
examiner or coroner to identify a decease individual or to identify
the cause of death. If necessary, we also may release information
in order for funeral directors to perform their jobs.
Organ and tissue donation: our practice may release your
IIHI 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.
Research: Our practice may use and disclose your IIHI for
research purposes in certain limited circumstances. We
will obtain your written authorization to use your IIHI
for research purposes except when an IRB or Privacy Board has determined
that he waiver of your authorization satisfies the following: (I)
the use or disclosure involves no more than a minimal risk
to the individual’s
privacy based on the following: (a) an adequate plan to protect the identifiers
from improper use and disclosure; (b) 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 (c)
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, (ii) the research could
not practicably be conducted without the waiver; and (iii) the research
could not practicably be conducted without access to and use of the
PHI.
Serious Threat to Health or Safety: Our practice may use and disclose
your IIHI when necessary to reduce or prevent a 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.
Military: Our practice may disclose your IIHI if you are a member of
U.S. or foreign military forces (including veterans) if required
by the appropriate authorities.
National Security: Our practice may disclose your IIHI to federal officials
for intelligence and national security activities authorized by law.
We also may disclose your IIHI to federal officials in order to protect
the President, other officials or foreign heads of state, or to conduct
investigations.
Inmates: Our practice may disclose your IIHI 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 for 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 IIHI for workers’ compensation
and similar programs.
Your rights regarding IIHI
You have the following rights regarding
the IIHI that we maintain about you:
Confidential communication: 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
at work. In order to request a type of confidential communication, you
must make a written request to the Office Manager, telephone 404-292-5600,
extension 14, specifying the requested method of contact,
or the location where you wish to be contacted. Our practice will accommodate
reasonable requests. You do not have to give a reason for your request.
Requesting restrictions: you have the right to request a restriction
in our use or disclosure of your IIHI for treatment,
payment, or health care operations. Additionally, you have the right to
request that we restrict our disclosure of your IIHI
to only certain individual involved in your care or the payment of 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 IIHI, you must make your request in writing
to Office Manager, 2665 North Decatur Road, Suite 325,
Decatur, Georgia 30033. 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
Inspection and Copies: you have the right to inspect and obtain a copy
of the IIHI 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,
2665 North Decatur Road, Suite 325, Decatur, Georgia 30033 in order
to inspect and/or obtain a copy of your IIHI. Our practice may charge a
fee for the costs of copying, mailing, labor, and supplies associated with
your request. Should you want to personally review the original copy
of your chart in our office, you must make an appointment to do so at a
time when the physician is present and the charge for this appointment
will be $75.00. 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.
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, 2665 North Decatur Road, Suite 325, and Decatur, Georgia
30033. 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 IIHI kept by
or for the practice; (c) not part of the IIHI 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.
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 IIHI for non-treatment or operations purposes. Use of your IIHI
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, 2665 North Decatur Road,
Suite 325, Decatur, Georgia 30033. All requests for “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.
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 copy of this notice,
contact Office Manager, telephone 404-292-5600, extension 14.
Right to file a complaint: if you feel that your privacy rights have
been violated, you may file a complaint with our practices or with
the Secretary of the Department of Health and Human Services. To
file a complaint with our practice, contact Privacy Officer, 2665
North Decatur Road, Suite 325, Decatur, Georgia 30033. All complaints
must be in writing. You will not be penalized for filing a complaint.
Right
to provide an authorization for other uses and disclosures: our
practice will obtain your written permission for uses and disclosures that
are not identified by this notice or permitted by applicable law. Any authorization
you provide to use regarding the use and disclosure of your IIHI
may be revoked at any time in writing. After you revoke your authorization,
we will no longer use or disclose your IIHI for the reasons described in
the authorization. Please note, we are required to retain records of your
care.
