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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment.  This information may be disclosed for the purpose of providing health care services to you, to assist in acquiring payment for your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party.  For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you appropriately.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, we submit requests for payment to your health insurance company.  The health insurance company (or other business associate helping us obtain payment) may request information from us regarding medical care provided to you.  We will share information with them about you and the care given.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of this physician group practice. These activities include, but are not limited to, quality assessment activities, employee review activities, third party educational/training programs, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information as part of a quality assessment review.  In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment or to inform you about treatment alternatives or other health related services of potential interest.

We may use or disclose your protected health information in some situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Workers’ Compensation:  Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.  Please see Amendment A for a partial list of “Other Uses and Disclosures” that may not require your consent.

Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

Following is a statement of your rights with respect to your protected health information.

You have the right to request to inspect and copy your protected health information.   You may exercise this right by delivering the request in writing to our office using the form that we provide to you upon request.  Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing, and must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to request that your physician amend your protected health information to correct incomplete or incorrect information.  This may be done by delivering a written request to our office using the form that we provide to you upon request. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.  An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care.  You may request this accounting by delivering a written request to our office using the form that we provide to you upon request.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint.  Our privacy contact is the Executive Director of LeBauer Medical Center, PLLC.  We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We reserve the right to change the terms of this notice and will inform you by mail and/or on your next visit to our office of any changes.  Any change will continue to be in full compliance with applicable federal and state regulations.  After reviewing any revised notice, you then have the right to object or withdraw as provided in this notice.

We (our medical group practice) are required by law to maintain the privacy of your health information, and provide patients with this Notice of our legal duties and privacy practices with respect to all protected health information. Further we are required to abide by the terms of this Notice, notify you if we cannot accommodate a requested restriction or request related to your PHI, and accommodate your reasonable requests regarding methods to communicate health information with you.  If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Office Phone Number (336) 282-2300.

Attachment A

Other Disclosures and Uses

Notification - Unless you object, we may use or disclose your protected health information to notify, or assist in notifying a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family - Using our best judgement, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.

Research - We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Disaster Relief - We may use and disclose your protected health information to assist in disaster relief efforts.

Funeral Directors or Coroners - We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Organ Procurement Organizations - Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Marketing - We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you.

Food and Drug Administration (FDA) - If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health - As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse & Neglect - We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Law Enforcement - We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight - Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings - We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Serious Threat to Health or Safety - To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions - We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Other Uses - Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with written authorization and you may revoke the authorization as previously provided.

Website - If we maintain a website that provides information about our entity, this Notice will be on the website.

Effective Date:  April 14, 2003

If you have questions or comments or need more information, call or email us!

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