Notice of Privacy Practices
Adult Medicine of Marietta, P.C.
Cindi Haga, Privacy Officer- Telephone (678) 797-8201
Effective Date: September 20, 2004
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.
The doctor(s) and staff of Adult Medicine of Marietta, PC understand the importance of keeping the medical and personal information you give us private and confidential. When we provide care to you we make a record of the services we provide. We may also receive such records from others. We use these records to:
- Provide care to you, or to help other health care providers to provide quality medical care to you;
- Obtain payment for services provided to you as allowed by your health plan; and
- Allow us to meet our professional and legal obligations to operate this medical practice properly.
We are required by law to maintain the privacy of protected health information. We are also required to provide our patients with a notice of our legal duties and the privacy practices we use to protect health information. This notice describes how we may use and share your medical information with others. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer at the number listed above.
A. How this Medical Practice May Use or Disclose (Share) Your Health Information
B. When This Medical Practice May Not Use or Disclose Your Health Information
C. Your Health Information Rights
1. Right to Request Special Privacy Protections
2. Right to Request Confidential Communications
3. Right to Inspect and Copy
4. Right to Amend or Supplement
5. Right to an Accounting of Disclosures
6. Right to a Paper Copy of this Notice
D. Changes to this Notice of Privacy Practices
E. Complaints
A. How this Medical Practice May Use or Disclose (Share) Your Health Information
This medical practice collects health information about you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or share information from your file for the following purposes:
1. Treatment. We use medical information about you to diagnose a medical problem, treat you, or help in prevention of disease. We may also share this information with doctors and other employees in our practice who treat you. We may also need to share information with:
- other doctors, hospitals or others who will provide services which we do not provide, a pharmacist who needs it to fill a prescription for you, a laboratory that performs a test, to members of your family or others who can help you when you are sick or injured.
2. Payment. We may use and share medical and personal information about you to obtain payment for the services we provide. For example, we must give your medical and some personal information to your health plan before it will pay us. We may also share some of your information to other doctors, labs, hospitals, etc., to help them get paid for their services.
3. Health Care Operations. We may use and share information in your file to help operate this medical practice. For example, we may use or share your information:
- to review and improve the quality of our patient care,
- to get your health plan to approve treatment or referrals,
- when necessary for medical reviews,
- legal services, or accounting services,
- and for business planning and management.
To help manage our practice, we may also share your information with our "business associates," such as our computer billing service. We have a written contract with each of these business associates that requires them to protect the confidentiality of your medical and personal information.
Your health plan may also request information to help them improve quality, reduce health care costs, or change their benefit programs.
4. Appointment Reminders. We may use your personal and medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.
5. Sign in sheet. We may use and share your personal or medical 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.
6. To Contact Your Family or Other Persons Involved in Your Care - . We may share your health information to notify or to help others notify a family member, your personal representative, or another person involved with your care. We may need to notify them of:
- your location,
- your general condition ,
- or of your death,
In the event of a disaster, we may share information with a group, like the Red Cross, so that they may help notify your family or other personal representatives.
We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and can be contacted, we will ask you if you have any objections before we share this information.
During a disaster or case of an emergency, we may give this information to others, even if you do object, if we believe it is necessary to handle the emergency circumstances. If you are not able to communicate with us, your doctors and other health care workers will use their best judgment in discussing your information with your family and others.
7. Marketing. We want to assure you that our practice does not share or sell your personal information for marketing purposes, unless we have your written permission. However, we may contact you to give you information about products or services related to the management of your health care. We may also let you know about other treatments, or health-related benefits and services that may be of interest to you. Sometimes we may offer you small gifts to help promote preventive care. When we see you, we may also encourage you to purchase a product or service that may be helpful in managing your healthcare.
8. Required by Law or Public Safety. There are many state and federal laws that require our practice to report certain health care information without your permission. We will limit the information we report only to that required to satisfy the requirements of the law. Examples include:
- To report abuse, neglect or domestic violence,
- To respond to a court order for information
- To provide Information needed by police, FBI or other law enforcement officials.
- To prevent or control disease, injury or disability;
- To report child, elder or dependent adult abuse or neglect;
- To report domestic violence;
- To report problems with products and reactions to medications to the Food and Drug Administration; To report disease or infection exposure.
When we report suspected domestic violence or abuse of an elder or an adult dependent, we will usually inform you or your personal representative, promptly. We may not notify you or your representative if, in our best professional judgment, we believe that notification would place you or another persona at risk of serious harm.
9. Health oversight activities. We may, and are sometimes required by law to disclose your health information to public health agencies that audit, investigate, and inspect, health records, subject to the limitations imposed by federal and state law.
10. Legal Requests and Court Ordered Information. We may be required by law to release your health information because of a legal action, such as a court case. We will release only the information authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process. We will make reasonable efforts notify you of the request. This will allow you to object to the court or through your legal representative.
11. Coroners. We may be required by law, to disclose your health information to coroners in connection with their investigations of deaths.
12. Organ or tissue donation. We may disclose your health information to organizations involved in obtaining, storing or transplanting organs and tissues.
13. Specialized government functions. We may disclose your health information for military or national security purposes, or to correctional institutions or law enforcement officers that have you in their lawful custody.
14. Worker's compensation. We may be required to share your information with doctors or others under worker's
compensation laws. For example, your case is covered by Worker's Compensation:
- We will make periodic reports to your employer about your condition
- We are also required by law to report
cases of occupational injury or
- occupational illness to the employer or
- workers' compensation insurer.
15. Change of Ownership. If our medical practice is sold or merges with another organization, your medical records will become the property of the new owner. You still have the right to request that copies of your chart be transferred to another doctor or medical group.
16. Research. We may disclose your health information to researchers conducting research with respect to which your written authorization is not required as approved by an Institutional Review Board or privacy board, in compliance with governing law.
B. When This Medical Practice May Not Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, this medical practice will not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
C. Your Health Information Rights
1. Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your health information, by a written request specifying what information you want to limit and what limitations on our use
or disclosure of that information you wish to have imposed. We reserve the right to accept or reject your request, and will notify you of our decision.
2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.
3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect it or get a copy of it. We will charge a reasonable fee, as allowed by Georgia law. We may deny your request under limited circumstances. If we deny your request to access your child's records because we believe allowing access would be reasonably likely to cause substantial harm to your child, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.
4. Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. You also have the right to request that we add to your record a statement of up to 250 words concerning any statement or item you believe to be incomplete or incorrect.
5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 16 (specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.
6. You have a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.
D. Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice.
After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area, and will offer you a copy at each appointment.
E. Complaints
Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: Department of Health and Human Services, Office of Civil Rights
You will not be penalized for filing a complaint.
Complaints submitted to the DHHS Office for Civil Rights should be directed to:
Office for Civil Rights/U.S. Department of Health & Human Services
61 Forsyth Street, SW.
Suite 3B70
Atlanta, GA 30323
(404) 562-7886
(404) 331-2867 (TDD)
(404) 562-7881 FAX
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