MEDINA HEALTHCARE

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

I. OUR PLEDGE REGARDING HEALTH INFORMATION: 

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. Your healthcare provider will need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this practice. This notice will tell you about how your provider may use and disclose health information about you. We also describe your rights to the health information we keep about you and describe certain obligations I have regarding the use and disclosure of your health information. We are required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to      health information.
• Follow the terms of the notice that is currently in effect.
• We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon      request, in the office, and on the website.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment or Health Care Operations: Federal privacy rules (regulations) allow healthcare providers who have a direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any healthcare provider. This too can be done without your written authorization. For example, if a health care provider were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, to assist the health care provider in the diagnosis and treatment of your condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because other healthcare providers need access to the full record and/or full and complete information to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Session      Notes: I do keep “Session notes” and any use or disclosure of such notes      requires your Authorization unless the use or disclosure is:
2. a.      For my use in treating you.
3. b.      For my use in training or supervising associates to help them improve      their clinical skills.
4. c.      For my use in defending myself in legal proceedings instituted by you.
5. d.      For use by the Secretary of Health and Human Services to investigate my      compliance with HIPAA.
6. e.      Required by law and the use or disclosure is limited to the requirements      of such law.
7. f.      Required by law for certain health oversight activities pertaining to the      originator of the session notes.
8. g.      Required by a coroner who is performing duties authorized by law.
9. h.      Required to help avert a serious threat to the health and safety of      others.
10. Marketing      Purposes. As a health care provider, I will not use or disclose your PHI      for marketing purposes.
11. Sale      of PHI. As a health care provider, I will not sell your PHI in the regular      course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When      disclosure is required by state or federal law, and the use or disclosure      complies with and is limited to the relevant requirements of such law.
2. For      public health activities, including reporting suspected child, elder, or      dependent adult abuse, or preventing or reducing a serious threat to      anyone’s health or safety.
3. For      health oversight activities, including audits and investigations.
4. For      judicial and administrative proceedings, including responding to a court      or administrative order, although my preference is to obtain an      Authorization from you before doing so.
5. For      law enforcement purposes, including reporting crimes occurring on my      premises.
6. To      coroners or medical examiners, when such individuals are performing duties      authorized by law.
7. For      research purposes, including studying and comparing the patients who      received one form of care versus those who received another form of care      for the same condition.
8. Specialized      government functions, including, ensuring the proper execution of military      missions; protecting the President of the United States; conducting      intelligence or counterintelligence operations; or, helping to ensure the      safety of those working within or housed in correctional institutions.
9. For      workers’ compensation purposes. Although my preference is to obtain an      Authorization from you, I may provide your PHI in order to comply with      workers’ compensation laws.
10. Appointment      reminders and health-related benefits or services. I may use and disclose      your PHI to contact you to remind you that you have an appointment with      me. I may also use and disclose your PHI to tell you about treatment      alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures      to family, friends, or others. I may provide your PHI to a family member,      friend, or other person that you indicate is involved in your care or the      payment for your health care, unless you object in whole or in part. The      opportunity to consent may be obtained retroactively in emergency      situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The      Right to Request Limits on Uses and Disclosures of Your PHI. You have the      right to ask me not to use or disclose certain PHI for treatment, payment,      or health care operations purposes. I am not required to agree to your      request, and I may say “no” if I believe it would affect your health care.
2. The      Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full.      You have the right to request restrictions on disclosures of your PHI to      health plans for payment or health care operations purposes if the PHI      pertains solely to a health care item or a health care service that you      have paid for out-of-pocket in full.
3. The      Right to Choose How I Send PHI to You. You have the right to ask me to      contact you in a specific way (for example, home or office phone) or to      send mail to a different address, and I will agree to all reasonable      requests.
4. The      Right to See and Get Copies of Your PHI. Other than “session notes,” you      have the right to get an electronic or paper copy of your medical record      and other information that I have about you. I will provide you with a      copy of your record, or a summary of it, if you agree to receive a      summary, within 30 days of receiving your written request, and I may      charge a reasonable, cost based fee for doing so.
5. The      Right to Get a List of the Disclosures I Have Made.You have the right to      request a list of instances in which I have disclosed your PHI for      purposes other than treatment, payment, or health care operations, or for      which you provided me with an Authorization. I will respond to your      request for an accounting of disclosures within 60 days of receiving your      request. The list I will give you will include disclosures made in the      last six years unless you request a shorter time. I will provide the list      to you at no charge, but if you make more than one request in the same      year, I will charge you a reasonable cost-based fee for each additional      request.
6. The      Right to Correct or Update Your PHI. If you believe that there is a      mistake in your PHI, or that a piece of important information is missing      from your PHI, you have the right to request that I correct the existing      information or add the missing information. I may say “no” to your      request, but I will tell you why in writing within 60 days of receiving      your request.
7. The      Right to Get a Paper or Electronic Copy of this Notice. You have the right      to get a paper copy of this Notice, and you have the right to get a copy      of this notice by e-mail. And, even if you have agreed to receive this      Notice via e-mail, you also have the right to request a paper copy of it.

Acknowledgment of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information.