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 information about you and your health care is personal. “Protected Health Information,” means any information that we receive or create that identifies (or could identify) you including demographic information (name, address, phone number, etc.) and deals with your physical or mental health, any services you receive at OB/GYN Centre of Excellence, and/or payment for such services. We follow strict federal and state laws requiring us to maintain the privacy of your protected health information. Federal and state laws may vary in the level of privacy protection. When the laws differ, we comply with the federal or Tennessee State law that provides the greatest protection for your health information excluding disclosures made to you or to the Secretary of Health and Human Services.
We are required to provide you this notice of our legal duties and privacy practices with respect to your protected health information. We are required to abide by the terms of the notice currently in effect. We reserve the right to change the terms of this notice. If there are any changes, you may obtain a revised copy by asking for one at the time of your next appointment; or by contacting the office at (423-629-9743), to receive a copy by mail. This notice takes effect April 14, 2003, and will remain in effect until we replace it.
I. USE AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
This section describes how we may use and disclose your protected health information as permitted or required by law. Your information may be used and/or disclosed by staff and others outside OB/GYN Centre of Excellence that are involved in your care and treatment. Except in certain circumstances, we must use or disclose only the minimum amount of information necessary to accomplish the purpose of the use or disclosure. The following categories contain explanations of the ways we may use or disclose your protected health information. Not every use or disclosure in a category will be listed. However, all
of the ways we are permitted to use and disclose information will fall within one of the categories.
Treatment. We may use and disclose your information to provide services to you and/or to coordinate care with other health care providers. For example, we may notify your primary care physician, with your permission, if you experience a change in your physical health.
Payment. We may use and disclose your protected health information to obtain payment for the services you receive at OB/GYN Centre of Excellence. For example, we may disclose information related to your treatment to contracted funding sources. Your information may also be used or disclosed to determine eligibility for services and insurance verification.
Business Associates. We may disclose your protected health information with business associates who perform various services or activities for OB/GYN Centre of Excellence. When we contract with other agencies for services or activities that involve the use or disclosure of protected health information, we will have a written agreement that requires the agency to protect the privacy of your information.
Appointment Reminders, Mailings, and Outreach. We may use your protected health information to remind you of appointments or appointments arranged by us on your behalf. Your name and address may be used to send you updated account information.
As Required by Law. We will disclose your protected health information as required by federal, state, or local law. The use or disclose is limited to the relevant requirements of such law. You will be notified of any such disclosure as required by law.
Disclosures for Judicial and Administrative Proceedings. We may disclose your protected health information in response to a court or administrative tribunal order, subpoena, discovery request, or other lawful process. Information may only be disclosed, if efforts have been made to notify you about the request or to obtain an order protecting the information requested.
Workers’ Compensation. We may disclose protected health information for workers’ compensation or similar programs established by law that provide benefits for work-related injuries or illness.
Research. We may disclose protected health information to Chattanooga Medical Research for study selection. Your name, address, and telephone number may be used to send you notification of study eligibility.
II. USE AND DISCLOSURES REQUIRING THE OPPORTUNITY TO AGREE OR OBJECT
You have the opportunity to agree or object to the following uses and disclosures of your protected health information. If you are not present or are not able to agree or object to the use or disclosure, then OB/GYN Centre of Excellence may, in the exercise of professional judgment, determine if the use or disclosure is in your best interest.
With your permission, we may disclose information to a family member, friend, or other person you identify who is involved in your care.
III. DISCLOSURES BASED ON YOUR AUTHORIZATION
Other use and disclosures not covered by this notice or other applicable laws may only be made with your written authorization. You may revoke your authorization at any time, in writing, except to the extent that we have already taken action based on your authorization.
IV. YOUR RIGHTS
Right to receive confidential communications by alternative means or at an alternative location. We will accommodate reasonable requests to receive communications of protected health information in a certain way or at a certain location. For example, you may request that we only contact you at home or by mail. We will not ask you the reason for the request. Your request must be submitted in writing to the OB/GYN Centre of Excellence staff. Your request must specify how or where you wish to be contacted.
Right to request restrictions. It is your right to request a restriction as to how your protected health information is used or disclosed for treatment, payment, and health care operations. You may also request that your protected health information not be disclosed to family members or friends involved in your care or for notification purposes as described above.
We are not required to agree to your restriction request. However, if we do agree to a restriction, we are required to follow it unless the information is needed to provide emergency treatment. If restricted information is used or disclosed to a health care provider in an emergency situation, we will request that the health care provider not further disclose the information. Restriction requests must be submitted in writing to the Office Manager.
Right to inspect and copy. You have the right to inspect and to obtain a copy of your protected health information. Under federal law, however, you may not access information compiled in reasonable anticipation of, or for use in a civil, or administrative action or proceeding.
Access. You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access.
Right to request amendment. If you feel your protected health information is incorrect or incomplete, you have the right to request an amendment for as long as we maintain the information. Your request for amendment must be submitted in writing to the Office Manager. If we accept your request, we will make the appropriate amendments to your information. With your agreement, we will also notify persons who previously received the information and need the amendment.
We may deny your request for amendment, if it is determined that the information is accurate and complete. Information not created by OB/GYN Centre of Excellence is not subject to amendment, unless the person or agency that created the information is no longer available to make the amendment. We may also deny a request, if the information is not part of the designated record set or would not be available for you to inspect.
If we deny your request, you have the right to file a statement of disagreement. We may prepare a rebuttal to your statement. You will receive a copy of the rebuttal, if one is prepared.
Right to receive an accounting of disclosures. You have the right to receive an accounting or list of disclosures we have made, if any, of your protected health information. The list does not include disclosures made:
For the purposes of treatment, payment, or health care operations:
To you or for emergency notification purposes as described above;
Based on your written authorization to release information;
For national security purposes or to law enforcement officials.
If you believe your privacy rights have been violated, you may file a complaint with us by contacting the Office Manager at (423) 629-9743. You may also file a complaint with the Secretary of Health and Human Services, Region IV Office of Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth Street, SW., Atlanta, GA 30303-8909. You will not be penalized for filing a complaint.