Notice of Privacy Statement
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
We are required by applicable federal and state
law to maintain the privacy of your health information. We are also
required to give you this Notice about our privacy practices, our legal
duties, and your rights concerning your health information. We must
follow the privacy practices that are described in this Notice while it
is in effect. This notice will remain in effect until we replace it.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Payment: We may use and disclose
your health information to obtain payment for services we provide to
you. This may include: (a) billing and collection activities and
related data processing; (b) actions by a health plan or insurer to
obtain premiums or to determine or fulfill its responsibilities for
coverage and provision of benefits under its health plan or insurance
agreement, determinations of eligibility or coverage, adjudication or
subrogation of health benefit claims; (c) medical necessity and
appropriateness of care reviews, utilization review activities; and (d)
disclosure to consumer reporting agencies of information relating to
collection of premiums or reimbursement.
To You, Your Family and Friends: We must disclose
your health information to you, as described in the Patient Rights
section of this Notice. We may disclose your health information to a
family member, friend or other person to the extent necessary to help
with your healthcare or with payment for your healthcare, but only if
you agree that we may do so or, if you are not able to agree, if it is
necessary in our professional judgment.
National Security: We may disclose
to military authorities the health information of Armed Forces
personnel under certain circumstances. We may disclose to authorized
federal officials health information required for lawful intelligence,
counterintelligence, and other national security activities. We may
disclose to correctional institution or law enforcement official having
lawful custody of protected health information of inmate or patient
under certain circumstances.
PATIENT RIGHTS
Access: You have the right to
review or get copies of your health information, with limited
exceptions. You may request that we provide copies in a format other
than photocopies. We will use the format you request unless we cannot
practicably do so. You must make a request in writing to obtain access
to your health information. You may obtain a form to request access by
using the contact information listed at the end of this Notice. We will
charge you a reasonable cost-based fee for expenses such as copies and
staff time. You may also request access by sending us a letter to the
address at the end of this Notice. If you request an alternative
format, we will charge a cost-based fee for providing your health
information in that format. If you prefer, we will prepare a summary or
an explanation of your health information for a fee. Contact us using
the information listed at the end of this Notice for a full explanation
of our fee structure.
Disclosure Accounting: You have
the right to receive a list of instances in which we or our business
associates disclosed your health information for purposes, other than
treatment, payment, healthcare operations, where you have provided an
authorization and certain other activities, for the last 6 years, but
not for disclosure made prior to
Amendment: You have the right to request that we
amend your health information. Your request must be in writing, and it
must explain why the information should be amended. We may deny your
request under certain circumstances.
QUESTIONS AND COMPLAINTS
Fax: 866-800-8809
E-mail: [email protected]