ARFP HIPAA
Effective Date of this Notice: April 14, 2003
Autumn Road Family Practice, P.A.
904 Autumn Road Suite 200
Little Rock, AR 72211
As Required by the Privacy Regulations Created as a Result of the Health
Insurance Portability and Accountability Act of 1996 (HIPAA)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS
PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR
INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY
A. 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
will 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 also are required by law to provide
you with this notice of our legal duties and the privacy practices that we
maintain in our practice concerning you 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 most current Notice at any time.
B. If you have questions about this notice, please contact:
Judy Canant, Privacy Officer
904 Autumn Road Suite 200
Little Rock, AR 72211
501-227-6363 Ext. 105 or jcanant@arfp.com
C. We may use and disclose your individually identifiable health
information (IIHI) in the following ways:
The following categories describe the different ways in which we may use and
disclose your IIHI.
1. 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.
2. 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.
We may disclose your IIHI to an outside agency if needed for collection efforts.
3. HealthCare 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 you 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.
4. Appointment Reminders. Our practice may use and disclose your IIHI
to contact you and remind you of an appointment by phone, mail or e-mail.
5. Treatment Options. Our practice may use and disclose your IIHI to
inform you of potential treatment option or alternative.
6. 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.
7. Release of Information to Family/Friends. Our practice may release
your IIHI to a friend or 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 doctor’s office for treatment of a
cold. In this example, the babysitter may have access to this child’s
medical information.
8. Disclosures Required by Law. Our practice will use and disclose your
IIHI when we are required to do so by federal, state or local law.
D. Use and disclosure of your IIHI in certain special circumstances
The following categories describe unique scenarios in which we may use or
disclose your identifiable health information:
1. 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 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.
2. 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.
3. Lawsuits and similar proceedings. Our practice may use and 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 your
of the request or to obtain an order protecting the information the party has
requested.
4. 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 or victim(s) of
the crime, or the description, identity or location of the perpetrator)
5. Deceased Patients. Our practice may release IIHI to a medical
examiner or coroner to identify a deceased individual or to identify the cause
of death. If necessary, we also may release information in order for
funeral directors to perform their jobs.
6. 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.
7. 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 the 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.
8. Serious Threats to Health or Safety. Our practice may use and
disclose your IIHI when necessary to reduce or prevent a serious 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.
9. Military. Our practice may disclose your IIHI if you are a
member of the U. S. Or foreign military forces (including veterans) and if
required by the appropriate authorities.
10. 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.
11. 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 to
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.
12. Workers’ Compensation. Our practice may release your IIHI for
workers’ compensation and similar programs.
E. YOUR RIGHTS REGARDING YOUR IIHI
You have the following rights regarding the IIHI that we maintain about you:
1. Confidential Communications. 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 work. In order to request a type of
confidential communication, you must make a written request to Judy Canant,
Privacy Officer, 501-227-6363 or jcanant@arfp.com specifying the requested
method of contact, or the location where you wish to be contacted. Our
practice will accommodate reasonable requests. You do not need to give a
reason for your request.
2. Requesting Restrictions. You have the right to request a restriction
in our use of 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 individuals involved in your care or
the payment for 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
Judy Canant, Privacy Officer, 501-227-6363 or jcanant@arfp.com. Your
request must describe in a clear and concise fashion:
A. The information you wish restricted;
B. Whether you are requesting to limit our practice’s use, disclosure or
both; and
C. To whom you want the limits to apply.
3. 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 Judy Canant, Privacy Officer,
501-227-6363 or jcanant@arfp.com 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. 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.
4. 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 Judy Canant,
Privacy Officer, 501-227-6363 or jcanant@arfp.com. 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
you 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 that information is not available
to amend the information.
5. 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 requested 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 Judy Canant, Privacy Officer, 501-227-6363 or jcanant@arfp.com. All
requests for an ‘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-mionth
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.
6. 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 paper copy of this notice,
contact Pat Richardson, Business Officer Manager at 501-227-6363.
7. Right to File a Complaint. If you believe your privacy rights have
been violated, you may file a complaint with our practice or with the Secretary
of the Department of Health and Human Services. To file a complaint with
our practice, contact Judy Canant, Privacy Officer, 501-227-6363 or
jcanant@arfp.com. We urge you to file your complaint with us first and
give us the opportunity to address your concerns. All complaints must be
submitted in writing. You will not be penalized for filing a complaint.
8. Right to provide an Authorization for Other Uses and Disclosures.
Our practice will obtain your written authorization for uses and disclosures
that are not identified by this notice or permitted by applicable law. Any
authorization you provide to us 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.
Again, if you have any questions regarding this notice or our health
information privacy policies, please contact:
Judy Canant, Privacy Officer
904 Autumn Road Suite 200
Little Rock, AR 72211
1-501-227-6363 Ext. 105 or jcanant@arfp.com