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.
WHO IS COVERED BY THIS NOTICE
This notice describes the privacy practices of the affiliated physician practice plans of Dr. Marie Ouellette, LLC including:
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Any health care professional authorized to enter information into your medical record.
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All employees and staff at Dr. Marie Ouellette, LLC
OUR PLEDGE REGARDING MEDICAL INFORMATION
We are required by law to:
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make sure that your health information is kept private;
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give you this notice of our legal duties and privacy practices; and
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follow the terms of the notice that is currently in effect.
We understand that your health information is personal. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. We are committed to protecting this information.
This notice will tell you about:
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the ways in which we may use and disclose your health information
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your rights; and
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our obligations regarding the use and disclosure of health information
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
We may use or share your health information in certain ways. We will explain how and when we may use or share your health information. We are not able to list each specific way we may use or share your health information, but each situation will fall into one of the basic types of situations below:
For Treatment. It is important that we be able to use or share your information to treat you. We may share your information to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. We may share your information with health care providers for your treatment.
For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We may need to share your information in order to schedule you for a surgery or procedure. Or a health care provider may need to know about any drug allergies that you have in order to provide you with appropriate medication.
For Payment. We may use or share your health information so that we are paid for the cost of your care. We may share your information with another provider so that they may be paid for services as well. We may bill, and share information with other providers, an insurance company, you, or a third party.
For example, we may need to give your health plan information about your diagnosis and treatment so your health plan will pay us or reimburse you for the care we provided. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may also share your health information in order to facilitate payment to another provider who has participated in your care.
Health-Related Benefits and Services. We may use and disclose medical information to tell you about treatment options, health-related benefits, or services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care We may release medical information about you to a family member or other designated person who is involved in your medical care. We may also give information to someone who helps pay for your care.
For example: We may need to tell the person who comes to pick you up after the appointment what he or she may need to do to help you once you get home.
In the event of an emergency. We may need to use or share information about you in order to inform your family or persons responsible for your care where you are, and your condition. In addition, we may disclose medical information about you to an agency assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
SPECIAL SITUATIONS: Additional uses and disclosures for which authorization or opportunity to agree or object is not required by HIPAA.
Research It can help find cures for diseases and help you and many other people. Under certain circumstances, we may use and disclose medical information about you for research purposes.
Often, you will need to give permission before we share your information with others for use in research. If your information is used, the researcher must keep your information safe and confidential.
As Required by Law We will disclose medical information about you when required to do so by federal, state or local law.
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.
Workers' Compensation We may release medical information to Workers' Compensation, as required by workers’ compensation laws. This program provides benefits for work-related injuries or illness.
Public Health Risks As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury, or disability; reporting medical device safety issues and adverse events to the federal Food and Drug Administration’s MedWatch program; and reporting disease or infection exposure.
Victims of Abuse, Neglect, or Domestic Violence We may disclose certain health information to government agencies authorized by law to receive reports of abuse, neglect, or domestic violence if we believe that you have been a victim.
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.
Judicial and Administrative Proceedings We may disclose your health information in the course of an administrative or judicial proceeding, such as in response to a court order
Law Enforcement We may release medical information to a law enforcement official if required or permitted by law.
Deceased Person Information We may release medical information to a coroner or medical examiner, or a funeral director as necessary to carry out their duties.
Specialized Government Functions We may release medical information about you to authorized federal officials for national security and intelligence, military, or veterans’ activities required by law.
USES OF MEDICAL INFORMATION THAT REQUIRE AUTHORIZATION
In all other situations (situations that are not treatment, payment, health systems operations or special situations, as we told you about above), we may only share information with your specific written authorization.
You may revoke that authorization, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except to the extent that we already have used or disclosed your information.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
Although the physical form of your medical information or designated record set is our business record and is the property of the health system, the information contained in those records is your information, and you have certain rights regarding that information.
YOU HAVE THE FOLLOWING RIGHTS REGARDING MEDICAL INFORMATION WE MAINTAIN ABOUT YOU:
Right to Review and Copy
You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care.
Usually, this information includes medical and billing records, but does not include psychotherapy notes, information compiled for use in or created in anticipation of a civil, criminal or administrative action or proceeding, or certain lab test results subject to the Clinical Laboratories Improvement Act of 1988.
You must submit your request for your medical information in writing to the office manager of the office where you received your care. 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.
Right to Appeal a Denial of Access to Medical Information
You have the right to access your medical information. There are some limitations on that right. If for clear treatment reasons your health provider has determined that access to your health information is likely to have an adverse effect on you, the health care provider shall provide the record to a practitioner designated by you to help you with your review of the information.
Your access is limited to your Designated Record Set. Your designated record set is information we used to make decisions about your care. It does not include:
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Information compiled for use in or created in anticipation of a civil, criminal or administrative action or proceeding, or
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Certain lab test results subject to the Clinical Laboratories Improvement Act of 1988.
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Other types of information that we did not use to make decisions about your health care.
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 an amendment for as long as the information is maintained. We may deny your request if you ask us to amend information that:
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is not part of the information which you would be permitted to inspect and copy; or
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we believe is accurate and complete.
Submit your request to the office manager of the office where you received your care. Your request must be made in writing and include a reason that supports your request.
Right to an Accounting of Disclosures
You have the right to request an accounting of disclosures. An accounting of disclosures is a listing of releases of your health information that we have made for the “Special Situations” listed in this Notice. We must document these disclosures and provide you with an accounting of them if we did not obtain your authorization before we released your information.
You must submit your request in writing to the HIPAA Privacy Contact in the office where you were seen.
Your request must:
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tell us the calendar dates you want to see. The time period cannot include more than six years of information, and cannot begin prior to April 14, 2003.
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indicate in what form you want the list (paper copy or electronic).
Charges: There will be no charge for the first list you request within a 12-month period. We may charge you for the costs of providing any additional lists. We will notify you of the cost involved. You may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. 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 emergency treatment.
You must make your request for any restrictions in writing to the office manager of the office where you received your care. 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).
Right to Request Confidential Communications
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.
You must make your request for confidential communications in writing to the office manager where you received your care. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. For example, if you wish to be contacted by telephone, be sure to provide an appropriate telephone number.
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. Contact a member of the office staff for a copy.
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. Current copies of this notice will be available at our office.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with our health system by either contacting the Office Manager at the office where you received your care or with the U.S. Office of Civil Rights, Washington, DC. All complaints must be submitted in writing. You will not be penalized for filing a complaint.