THE
ALLERGY & ASTHMA CENTER, P.C.
NOTICE
OF PRIVACY PRACTICES
(Effective
April 14, 2003)
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. If
you have any questions or need any additional information about this Notice of
Privacy Practices (Notice”), please contact The Allergy & Asthma Center,
P.C.’s (“AAC”) Contact Person at (260) 432-5005.
A.
AAC’S DUTIES
AAC
is required by the final Standards for Privacy of Individually Identifiable
Health Information (the “Privacy Standards”) to maintain the privacy of your
protected health information. In
addition, AAC is required by law to provide you with adequate notice of AAC’s
uses and disclosures of your protected health information, notice of your rights
with respect to your protected health information, and notice of AAC’s legal
duties with respect to your protected health information. This Notice is given
to you to satisfy AAC’s legal obligations to provide adequate notice to you.
AAC agrees to abide by the terms of its Notice then in effect.
AAC
is required to give this Notice to you no later than its first delivery of
services to you on or after April 14, 2003 (if the first service delivery to you
is delivered electronically, AAC will provide electronic notice of its privacy
practices automatically and contemporaneously in response to your first request
for service). In addition, AAC is
required to make its Notice available to you at any time upon your request, and
to post the Notice in a clear and conspicuous location in the waiting room of
each of AAC’s offices. AAC has a website at: www.allergyasthmacenter.com.
A copy of this Notice will be posted on that website and a copy of the
Notice will be available electronically through the website.
For
purposes of the Privacy Standards and this Notice, the term “protected health
information” means “individually identifiable health information”.
The term “individually identifiable health information” means health
information (whether oral or recorded in any form or medium), including
demographic information collected from you, that identifies you, or could
reasonably be used to identify you and which: is created or received by a health
care provider, health plan, public health authority, employer, life insurer,
school or university, or health care clearinghouse; and, relates to your past,
present, or future physical or mental health or condition, the provision of
health care to you, or the past, present, or future payment for the provision of
health care to you.
B.
How AAC May Use or Disclose YOUR Protected Health Information
As
a general rule, AAC may not use, disclose or request protected health
information about you except as required or permitted by the Privacy Standards.
Furthermore, except in limited circumstances, AAC must use,
disclose or request only the minimum necessary protected health
information to accomplish the purpose of the use, disclosure or request.
1.
Required Disclosures. The
following categories describe the instances in which AAC is required to disclose
your protected health information:
●
To You. AAC
is required to disclose protected health information about you to you when
requested by you in certain circumstances. Pursuant to the Privacy Standards,
you have the right to request access to your protected health information for
inspection and copying purposes and to request an accounting of disclosures.
Each of those rights in discussed in more detail in the “Your Rights
Regarding Protected Health Information About You” section of this Notice.
●
To the Secretary. AAC is
required to disclose protected health information to the Secretary of the
Department of Health and Human Services when the information is required in
order for the Secretary to investigate or determine whether AAC is in compliance
with the Privacy Standards.
2.
Permitted Uses and Disclosures. The
following categories describe the instances in which AAC is permitted to use and
disclose protected health information about you without obtaining your written
authorization. For each category, AAC has attempted to explain what it means and
has given examples. Not every use
or disclosure in a category will be listed.
However, all of the ways AAC may use and disclose information without
authorization will fall within one of the following:
● Treatment. AAC may use your protected health information to provide you with medical treatment or services. AAC may disclose protected health information about you to doctors, nurses, or other health care professionals who are involved in taking care of you. For example, AAC may be treating you for certain allergies. Those allergies may be relevant to care you may receive from another physician. As such, AAC may share your information with the other physician
●
Payment. AAC
may use or disclose your protected health information for purposes of receiving
payment for treatment and services you receive.
For example, AAC may give your insurance company information about your
treatment so the insurance company will pay AAC or reimburse you.
AAC may also tell your insurance company about treatment you are going to
receive to determine whether your insurance company will pay for it.
●
Health Care Operations.
AAC may use and disclose protected health information about you for
operational purposes. For example,
your protected health information may be disclosed to AAC’s health care
professionals to evaluate the performance of the health care professionals, to
assess the quality of care and outcomes in your cases and similar cases, to
learn how to improve AAC’s facilities and services, and, to determine how to
continually improve the quality and effectiveness of the health care AAC
provides.
●
Incidental Uses and Disclosures.
AAC may use and disclose protected health information about you incident
to a use or disclosure permitted or required by the Privacy Standards so long as
AAC has complied with the minimum necessary and safeguards requirements imposed
under the Privacy Standards. For
example, AAC’s nurses may discuss information about your care at the nursing
station, and if someone overhears that discussion, the disclosure to that person
will be permitted so long as the nurses discussed only the minimum necessary and
AAC took appropriate steps to put safeguards in place.
●
Appointment Reminders. AAC may
use and disclose protected health information about you to contact you as a
reminder that you have an appointment for treatment or medical care.
●
Treatment Alternatives. AAC
may use and disclose your protected health information to tell you about or to
recommend possible treatment options or alternatives that may be of interest to
you.
●
Health-Related Benefits and Services.
AAC may use and disclose your
protected health information to tell you about health-related benefits or
services that may be of interest to you.
●
Fundraising Activities. AAC
may use protected health
information about you to contact you in an effort to conduct fundraising
activities.
●
Business Associates.
AAC contracts with others outside of AAC’s organization to perform or
assist AAC in performing functions that involve the use and disclosure of
protected health information. For
example, AAC may contract with a billing company to do billing for AAC.
The billing company will need protected health information in order to
perform its job. As such, AAC may
disclose protected health information about you to business associates of AAC so
that the business associates can perform the job AAC has asked them to do.
In order to protect your protected health information, AAC will require
all of its business associates to make assurances to AAC they will each
appropriately safeguard your protected health information.
●
Individuals Involved in Your Care. In
certain circumstances, AAC may use or disclose protected health information
about you to a family member, relative or
close personal friend who is involved in your medical care. In addition, AAC may
disclose protected health information about you to notify or assist in the
notification of a family member, relative or
close personal friend who is involved in your medical care of your condition,
location and status.
●
Disaster Relief Efforts. In
certain circumstances, AAC may use or disclose protected health information
about you to a public or private entity authorized by law to assist in disaster
relief efforts for the purpose of coordinating with such entities.
● Personal Representatives. Except in limited circumstances, AAC must treat a personal representative of a decedent as the individual about who the protected health information relates. As such, AAC may disclose protected health information to your personal representative.
●
Adults and Emancipated Minors.
If a person has authority to act on behalf of an adult or an emancipated
minor in making decisions related to health care, AAC must treat that person as
a personal representative. As such,
except in limited circumstances, AAC may disclose protected health information
to your personal representative as if the disclosure was being made to you.
●
Unemancipated Minors. If,
under applicable law, a parent, guardian or other person acting in loco parentis
has authority to obtain access to protected health information about an
unemancipated minor, then AAC may disclose protected health information to the
person acting in loco parentis as if the disclosure was being made to the
unemancipated minor.
●
Required by Law. AAC
will disclose protected health information about you when it is required to do
so by federal, state or local law, rule or regulation.
For example, AAC may disclose information for the following purposes: for
judicial and administrative proceedings pursuant to legal authority; to report
information related to victims of abuse, neglect or domestic violence; and, to
assist law enforcement officials in their law enforcement duties.
●
Public Health/Health Oversight. AAC
may use or disclose protected health information about you for public health
activities such as assisting public health authorities or other legal
authorities to prevent or control disease, injury, or disability, or for other
health oversight activities.
●
Deceased Individuals.
AAC may disclose protected health Information to funeral directors,
medical examiners and/or coroners to enable them to carry out their lawful
duties.
●
Organ/Tissue Donation. AAC
may use or disclose protected health information about you for cadaveric organ,
eye or tissue donation purposes.
●
Research. AAC
may use or disclose protected health information about you for research
purposes. For example, a research
project may involve comparing the health and recover of patients who received
one medication to those who received another medication.
All research projects are subject to a special approval process.
Before AAC will use or disclose protected health information about you,
the project will be approved through the special approval process.
●
Health and Safety. AAC
may use or disclose your protected health information to avert a serious threat
to the health or safety of you or any other person pursuant to applicable law.
●
Specialized Government Functions. AAC
may use and disclose your protected health information for military and veterans
activities, for national security and intelligence activities, for protective
services of the President and others, and to correctional institutions and other
law enforcement custodial situations.
●
Workers’ Compensation. AAC
may use and disclose protected health information about you for workers’
compensation or similar programs to the extent authorized by and to the extent
necessary to comply with laws regarding said programs.
●
FDA Reporting. In
the event AAC is subject to the jurisdiction of the federal Food and Drug
Administration with respect to a product or activity for which AAC has a duty to
make reports of quality, safety or effectiveness, AAC may use and disclose
protected health information about you to make any fulfill any requirements
imposed by the FDA.
3.
Uses and Disclosures For Which Authorization is Required.
The following categories
describe the instances in which AAC
may only use and disclose protected health information about you after first
obtaining your written authorization:
a.
All Instances Except as Required or Permitted.
Except as required or permitted
by the Privacy Standards, AAC may not use or disclose protected health
information about you without your written
authorization. When AAC
receives your authorization to use or disclose your protected health
information, AAC must make its use and disclosure consistent with such
authorization. If you provide AAC
authorization to use or disclose your protected health information, you may
revoke that authorization, in writing, at any time.
If you revoke your authorization, AAC will no longer use or disclose your
protected health information for the reasons covered by your authorization.
However, your revocation will not be applicable to disclosures that AAC
already made prior to its receipt of your written revocation.
b.
Psychotherapy Notes.
AAC may not use and disclose psychotherapy notes without your
authorization except: to carry out certain treatment, payment and health care
operation activities; as required by law; for health oversight activities; to
coroners and medical examiners; and, to prevent or lessen a serious and imminent
threat to the health and safety of a person or the public.
c.
Marketing. AAC may not use and
disclose protected health information about you for marketing without your
authorization, except if the communication is in the form of:
face to face communication made by AAC to you;
or, a promotional gift of nominal value provided by AAC.
C.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
You
have the following rights regarding protected health information AAC maintains
about you:
1.
Request Restrictions.
You have the right to request that AAC restrict or limit how it uses or
discloses your protected health information for treatment, payment or health
care operations. AAC will consider
your request, but AAC is not required to agree to your request.
AAC cannot agree to limit uses and disclosures that are required by the
Privacy Standards. If AAC agrees to
your request, AAC will comply with your request unless the information is needed
to provide you emergency treatment or in other limited circumstances. To request
a restriction, you must make your request in writing to the Privacy Officer of
AAC. In your request, you must provide AAC with your name, address, a specific
description of the requested restriction, and the requested duration of the
restriction. The request must also
be signed and dated. Please refer
to 45 C.F.R §164.522 for a more detailed description of your rights.
2.
Request Confidential Communications.
You have the right to request that AAC communicate with you about medical
matters in a certain way or at a certain location.
For example, you can ask that AAC only contact you at work or by mail.
To request confidential communications, you must make your request in
writing to the Privacy Officer of AAC. In
your request, your must provide AAC with your name, address, a specific
description of the request, an identification of the alternate method of
communication and/or alternate address, and the duration of the request.
The request must also be signed and dated.
AAC will not ask you the reason for your request and AAC will accommodate
all reasonable requests. Please
refer to 45 C.F.R §164.522 for a more detailed description of your rights.
3.
Request Access to Inspect and Copy.
You have the right to request
access for purposes of inspecting and copying your protected health information.
To request access, you must make your request in writing to the Privacy
Officer of AAC. In your request, you must provide AAC with your name, address, a
description of the requested access (i.e., inspection, copying, both) and a
statement as to the requested form or format of the information.
The request must also be signed and dated.
AAC will respond to your request within 30 days (unless the information
is stored off-site, in which event AAC will respond within 60 days).
If AAC is unable to respond within that time, AAC may have an additional
30 days if it notifies you in writing as to the reason for the delay and gives
you the date on which it will respond. In
some instances, AAC may deny your request to inspect and copy.
If you are denied access to your protected health information, you may
request that the denial be reviewed in certain circumstances.
If you are entitled to a review, another licensed health care
professional chosen by AAC will review your request and the denial.
The person conducting the review will not be the person who denied your
request. AAC will comply with the
outcome of the review. If you
request a copy of the information, AAC may charge a fee for the cost of copying,
mailing and other supplies associated with your request.
Please refer to 45 C.F.R §164.524 for a more detailed description of
your rights.
3.
Request Amendments. If
you feel that protected health information AAC has about you is incorrect or
incomplete, you have the right to request that AAC to amend the information.
You have the right to request an amendment for as long as the information
is kept by or for AAC. To request
an amendment, you must make your request in writing to the Privacy Officer of
AAC. In your request, you must provide AAC with your name, address, a specific
description of the requested amendment and a description of the reason or basis
for the amendment. The request must also be signed and dated.
AAC will respond to your request within 60 days.
If AAC is unable to respond within that time, AAC may have an additional
30 days if it notifies you in writing as to the reason for the delay and gives
you the date on which it will respond. In
some instances, AAC may deny your request for an amendment.
If AAC denies your request, you will be given the opportunity to submit a
written statement of disagreement and/or request in writing that AAC include
your request with any future disclosures of the affected information.
In the event you file a written statement of disagreement, AAC will be
allowed to prepare a written rebuttal. In
some instances, the future disclosures of the affected information will include
your request, the denial, your written statement and the rebuttal.
Please refer to 45 C.F.R §164.526 for a more detailed description of
your rights.
4.
Request an Accounting of Disclosures.
You have the right to request an accounting of disclosures describing
certain of the disclosures AAC has made of protected health information about
you. To request an accounting, you must make your request in writing to the
Privacy Officer of AAC. In your
request, you must provide AAC with your name, address, and a statement of the
period of time for the accounting (which may not be longer than six (6) years
and may not include dates before April 14, 2003).
Your request should indicate in what form you want the accounting (for
example, on paper, electronically, etc.) The request must also be signed and
dated. AAC will respond to your
request within 60 days. If AAC is
unable to respond within that time, AAC may have an additional 30 days if it
notifies you in writing as to the reason for the delay and gives you the date on
which it will respond. The first
accounting you request within a twelve (12) month period will be free of charge.
For additional accountings during a twelve (12) month period, AAC may
charge you for the cost of providing the accounting.
AAC will notify you of the cost involved in advance and you may choose to
withdraw or modify your request at that time before any costs are incurred.
Please refer to 45 C.F.R §164.528 for a more detailed description of
your rights.
5.
Request Paper Copy of this Notice.
You have the right to a paper copy of this Notice.
You may ask AAC 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, contact the Contact Person of AAC.
D.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint. To file a complaint with AAC, contact the Contact Person of AAC at (260) 432-5005. The Contact Person will inform you as to the formal procedure for filing a complaint with AAC and the Contact Person can assist you with respect to making a complaint. You will not be retaliated against for filing a complaint.
You
may also file a complaint with the Secretary of the Department of Health and
Human Services. To file a compliant
with the Secretary of the Department
of Health and Human Services, you should contact the Department of Health and
Human Services at: The U.S. Department of Health and
Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201;
(877)-696-6775 within one hundred eighty (180) days of when you knew or
should have known that the act or omission complained of occurred (this time
limit can be waived by the Secretary for good cause shown)).
You will not be retaliated against for filing a complaint.
E.
CHANGES TO THIS NOTICE
AAC
reserves the right to change its privacy practices and this Notice at any time.
AAC will promptly revise and distribute a revised Notice whenever
required by law or when there is a material change to: the uses or disclosures
that may be made by AAC; your rights with respect to your protected health
information; AAC’s legal duties; and/or AAC’s other privacy practices
described in this Notice. AAC
reserves the right to make the revised or changed privacy practices and Notice
effective for protected health information AAC already has about you as well as
any information AAC receives in the future.
AAC
will post a copy of the current Notice in the waiting room of each of AAC’s
offices. The Notice will contain on
the first page, in the top center section, the effective date.
In addition, each time you register at AAC’s office for treatment or
health care services, AAC will make available to you a copy of the current
Notice then in effect. AAC will also post a copy of its current Notice on its
website.
F.
EFFECTIVE DATE
This
Notice shall be effective on and after April
14, 2003.
G.
YOUR WRITTEN ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE
AAC is required to make a good faith effort to obtain your written acknowledgement of your receipt of this Notice. As such, please complete the attached form acknowledging your receipt of this Notice and give the completed form to a member of AAC.