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Notice
of Privacy Practices for Protected Health Information
for David M. Creech, M.D.
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
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This
office is required by federal regulation, known as the HIPAA Privacy Rule,
to maintain the privacy of your health information and to provide you with
notice of its legal duties and privacy practices.
This office will not use or disclose your health information except
as described in this Notice.
The
office is permitted by federal privacy laws to make uses and disclosures
of your health information for purposes of treatment, payment, and health
care operations. Protected health information is the information we create and
obtain in providing our services to you.
The health information about you is documented in a medical record
and on a computer. Such
information may include documenting your symptoms, medical history,
examination and test results, diagnoses, treatment, and applying for
future care or treatment. It
also includes billing documents for those services.
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| Examples
of uses of your health information for treatment purposes are:
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- A nurse or medical assistant obtains treatment information about you and records it in a health record.
- During the course of your treatment,
Dr. Creech determines he will need to consult with another specialist in the area. He will share the information with such specialist and obtain his/her input.
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| Example
of use of your health information for payment purposes:
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- We submit requests for payment to your health insurance company. The health insurance company (or other business associate helping us obtain payment) requests health information from us regarding medical care given. We will provide information to them about you and the care given, which may include copies or excerpts of your medical record, which are necessary for payment of your account. For example, a bill sent to your health insurance company may include information that identifies your diagnosis, and the procedures and supplies used.
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| Examples
of use of your health information for healthcare operations:
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- We obtain services from our insurers or other business associates (an individual or entity under contract with us to perform or assist us in a function or activity that necessitates the use or disclosure of health information) such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentially, medical transcription, medical transcription, medical review, legal services, and insurance. We will share health information about you with our insurers or other business associates as necessary to obtain these services. We require our insurers and other business associates to protect the confidentiality of your health information.
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Your
Health Information Rights
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| The
health and billing records we maintain are the physical property of the
office.
The information in it, however, belongs to you.
You have a right to:
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- Request a restriction on certain uses and disclosures
of your health information by delivering the request in writing to our
office. We are not required to grant the request but we will comply
with any request granted.
- Obtain a paper copy of the Notice of Privacy
Practices for Protected Health Information (“Notice”) by making a
request at our office;
- Request that you be allowed to inspect and copy your
medical record and billing record-you may exercise this right by
delivering the request in writing to our office using the form we
provide to you upon request;
- Appeal a denial of access to your protected health
information except in certain circumstances;
- Request that your healthcare record be amended to
correct incomplete or incorrect information by delivering a written
request to our office using the form we provide to you upon request.
(Dr. Creech is not required to make such amendments);
- File a statement of disagreement if your amendment is
denied, and require that the request for amendment and any denial be
attached in all future disclosures of your protected health
information;
- Obtain an accounting of disclosures of your health
information as required to be maintained by law by delivering a
written request to our office using the form we provide to you upon
request. An accounting will not include uses of information for
treatment, payment, or health care operations; disclosures or uses
made to you or made at your request; uses or disclosures made pursuant
to an authorization signed by you; or to family members or friends or
uses relevant to that person’s involvement in your care or in
payment for such care; or uses or disclosures to notify family or
others responsible for your care, of your location, condition, or your
death; we may charge a cost-based fee for more than one accounting in
a 12-month period;
- Request that communication of your health information
be made by alternative means or at an alternative location by
delivering the request in writing to our office using the form we give
you upon request; and
- Revoke authorizations that you made previously to use
or disclose information except to the extent information or action has
already been taken by delivering a written revocation to our office.
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If you want to exercise any of the above rights, please contact the office manager at (602) 431-9585 or 7776 S. Pointe Park Way West, Suite 135, Phoenix, Arizona 85044, in person or in writing, during normal hours. She will provide you with assistance on the steps to take to exercise your rights.
You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and healthcare purposes.
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| Our
Responsibilities
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| The
office is required to:
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- Maintain the privacy of your health information as required by law;
- Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
- Abide by the terms of this Notice;
- Notify you if we cannot accommodate a request restriction or request; and
- Accommodate your reasonable requests regarding methods to communicate health information with you.
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| We
reserve the right to amend, change, or eliminate provisions in our privacy
practices and access practices and to enact new provisions regarding the
protected health information we maintain.
If our information practices change, we will amend our Notice.
You are entitled to receive a revised copy of the Notice by calling
and requesting a copy of our “Notice” or by visiting our office and
picking up a copy.
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| To Request
Information or File a Complaint
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If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact our office manager at (602) 431-9585.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to our office manager. You may also file a complaint by mailing it or emailing it to the Secretary of Health and Human Services.
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- We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office.
- We cannot, and will not, retaliate against you for filing a complaint with HHS or OCR.
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| Other
Disclosures and Uses
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| Notification of Family/Friends
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- 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.
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| Communication with Family/Friends
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- Using our best judgment, we may disclose to a family member, or 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.
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| Research
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- We may disclose your health 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 health information.
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| Deceased Persons
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- We may disclose your health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
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| Appointment Reminders and Treatment Alternatives
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- We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information by other heath-related benefits and services that may be of interest to you.
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| Sign in Sheet
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- We may use and disclose your health information by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.
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| Food and Drug Administration (FDA)
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- We may disclose to the FDA your health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs or replacements.
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| Workers Compensation
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- If you are seeking compensation through Workers Compensation, we may disclose your health information to the extent necessary to comply with laws relating to Workers Compensation.
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| Public Health
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- As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
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| Abuse, Neglect & Domestic Violence
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- We may disclose your health information to public authorities as allowed by law to report abuse, neglect, or domestic violence.
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| Law Enforcement
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- We may disclose your health information for law enforcement purposes as required by law, such as when required by a court order; for identification of a victim of a crime if certain protective requirements are met; to report a crime on our premises; to report a crime in emergencies; and other appropriate situations permitted by law.
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| Health Oversight
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- We may disclose your health information to appropriate health oversight agencies or for health oversight activities.
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| Judicial/Administrative Proceedings
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- We may disclose your health information in the course of any judicial or administrative proceeding as allowed or required by law or as directed by a proper court order or in response to a subpoena, discovery request or other lawful process if certain specific requirements are met.
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| Serious Threat
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- To avert a serious threat to health or safety, we may disclose your 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.
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| For Specialized Governmental Functions
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- We may disclose your health information for specialized governmental functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
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| Other Uses
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- Other uses and disclosures of your health information besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.
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| Website
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- If we maintain a website that provides information about our entity, this Notice will be
on the website.
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Original Effective Date: April 14, 2003
Effective Date of Last Revision (if any): _________________
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