|
Northern
Colorado Surgical Associates, P.C.
Notice of Privacy Practices for Protected Health Information
Effective Date: April 14, 2003
Version 04142003.1
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
office/hospital 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.
Such information may include documenting your symptoms,
examination, and test results, diagnoses, treatment,
and applying for future care or treatment. It also includes
billing documents for those services.
Examples
of Uses of Your Health Information for Treatment Purposes
are:
|
| • |
A
nurse obtains treatment information about you and records
it in a health record. |
| • |
During
the course of your treatment, the physician determines
he/she will need to consult with another specialist in
the area. He/she will share the information with such
specialist and obtain his/her input. |
| • |
Results
of laboratory tests and procedures will be available
in your medical record to all health professionals.
|
| • |
Our
staff to send you appointment reminders will use your
health information. |
| • |
Your
health information may be used to send you information
on the treatment and management of your medical condition
that you may find to be of interest. |
| |
|
| Example
of Use of Your Health Information for Payment Purposes: |
| • |
We
submit requests for payment to your health insurance company.
The health insurance company (or other business associate
helping us obtain payment) requests and receive information
on dates of service, the medical care given and the medical
condition being treated. |
| |
|
| Example
of Use of Your Information for Health Care Operations: |
| • |
We
obtain services from our insurers or other business associates
such as quality assessment, quality improvement, outcome
evaluation, protocol and clinical guideline development,
training programs, credentialing, medical review, legal
services, and insurance. We will share information about
you with such insurers or other business associates as
necessary to obtain these services. |
| • |
Information
on the services you received may be used to support budgeting
and financial reporting, and activities to evaluate and
promote quality. |
| |
|
| Your
Health Information Rights |
| 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: |
| • |
Request
a restriction on certain uses and disclosures of your
health information by delivering the request 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 current 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 health record
and billing record – you may exercise this right
by delivering the request to our office; |
| • |
Appeal
a denial of access to your protected health information,
except in certain circumstances; |
| • |
Request
that your health care record be amended to correct incomplete
or incorrect information by delivering a request to our
office. We may deny your request if you ask us to amend
information that: |
| |
| • |
Was
not created by us, unless the person or entity that
created the information is no longer available to
make the amendment; |
| • |
Is
not part of the health information kept by or for
the office; |
| • |
Is
not part of the information that you would be permitted
to inspect and copy; or, |
| • |
Is
accurate and complete. |
|
| |
|
| If
your request is denied, you will be informed of the reason
for the denial and will have an opportunity to submit
a statement of disagreement to be maintained with your
records; |
| • |
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; |
| • |
Obtain
an accounting of disclosures of your health information
as required to be maintained by law by delivering a request
to our office. An accounting will not include uses and
disclosures of information for treatment, payment, or
operations; disclosures or uses made to you or made at
your request; uses or disclosures made pursuant to an
authorization signed by you; uses or disclosures made
in a facility directory or to family members or friends
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. |
| • |
Revoke
authorizations that you made previously to use or disclose
information by delivering a written revocation to our
office, except to the extent information or action has
already been taken. |
| |
|
| If
you want to exercise any of the above rights, please contact
our privacy officer (Gary Johnson) at (970) 482-6456 at
2121 E. Harmony Road, Suite 250, Fort Collins, CO 80528
in person or in writing, during regular business hours.
He will inform you of the steps that need to be taken
to exercise your rights. |
| |
|
| Our
Responsibilities |
| The
office is required to: |
| • |
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 requested restriction or
request; and, |
| • |
Accommodate
your reasonable requests regarding methods to communicate
health information with you. |
| |
|
| 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. |
| |
|
| To
Request Information or File a Complaint |
|
If
you have questions, would like additional information,
or want to report a problem regarding the handling of
your information, you may contact:
Privacy
Officer – Gary Johnson
Northern Colorado Surgical Associates, P.C.
2121 E. Harmony Road, Suite 250
Fort Collins, Colorado 80528
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
Privacy
Officer – Gary Johnson
Northern Colorado Surgical Associates, P.C.
2121 E. Harmony Road, Suite 250
Fort Collins, Colorado 80528
You
may also file a complaint by mailing it or e-mailing
it to the Secretary of Health and Human Services, whose
street address is: Office for Civil Rights - U.S. Department
of Health and Human Services - 200 Independence Avenue
S.W. - Room 509F, HHH Building - Washington, D.C. 20201.
|
| • |
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
our office. |
| • |
We
cannot, and will not, retaliate against you for filing
a complaint with the Secretary of Health and Human Services. |
| |
|
| Other
Disclosures and Uses |
| |
|
| Communication
with Family |
| • |
Using
our best judgment, we may disclose to a family member,
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. |
| |
|
| Notification |
| • |
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. |
| |
|
| Research |
| • |
We
may disclose information to researchers when an institutional
review board that has reviewed the research proposal and
established protocols to ensure the privacy of your protected
health information has approved their research. |
| |
|
| Disaster
Relief |
| • |
We
may use and disclose your protected health information
to assist in disaster relief efforts. |
| |
|
| Organ
Procurement Organizations |
| • |
Consistent
with applicable law, we may disclose your protected health
information to organ procurement organizations or other
entities engaged in the procurement, banking, or transplantation
of organs for the purpose of tissue donation and transplant.
|
| |
|
| Food
and Drug Administration (FDA) |
| • |
We
may disclose to the FDA your protected 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.
|
| |
|
| Workers'
Compensation |
| • |
If
you are seeking compensation through Workers' Compensation,
we may disclose your protected health information to the
extent necessary to comply with laws relating to Workers'
Compensation. |
| |
|
| Public
Health |
| • |
As
authorized by law, we may disclose your protected health
information to public health or legal authorities charged
with preventing or controlling disease, injury, or disability;
to report reactions to medications or problems with products;
to notify people of recalls; to notify a person who may
have been exposed to a disease or who is at risk for contracting
or spreading a disease or condition. |
| |
|
| Abuse
and Neglect |
| • |
We
may disclose your protected health information to public
authorities as allowed by law to report abuse or neglect. |
| |
|
| Employers |
| • |
We
may release health information about you to your employer
if we provide health care services to you at the request
of your employer, and the health care services are provided
either to conduct an evaluation relating to medical surveillance
of the workplace or to evaluate whether you have a work-related
illness or injury. In such circumstances, we will give
you written notice of such release of information to your
employer. Any other disclosures to your employer will
be made only if you execute a specific authorization for
the release of that information to your employer. |
| |
|
| Correctional
Institutions |
| • |
If
you are an inmate of a correctional institution, we may
disclose to the institution or its agents the protected
health information necessary for your health and the health
and safety of other individuals. |
| |
|
| Law
Enforcement |
| • |
We
may disclose your protected health information for law
enforcement purposes as required by law, such as when
required by a court order, or in cases involving felony
prosecution, or to the extent an individual is in the
custody of law enforcement. |
| |
|
| Health
Oversight |
| • |
Federal
law allows us to release your protected health information
to appropriate health oversight agencies or for health
oversight activities. |
| |
|
| Judicial/Administrative
Proceedings |
| • |
We
may disclose your protected health information in the
course of any judicial or administrative proceeding as
allowed or required by law, with your authorization, or
as directed by a proper court order. |
| |
|
| Serious
Threat |
| • |
To
avert a serious threat to health or safety, we may disclose
your protected 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. |
| |
|
| For
Specialized Governmental Functions |
| • |
We
may disclose your protected health information for specialized
government functions as authorized by law such as to Armed
Forces personnel, for national security purposes, or to
public assistance program personnel. |
| |
|
| Coroners,
Medical Examiners, and Funeral Directors |
| • |
We
may release health information to a coroner or medical
examiner. This may be necessary, for example, to identify
a deceased person or determine the cause of death. We
may also release health information about patients to
funeral directors as necessary for them to carry out their
duties. |
| |
|
| Fund
Raising |
| • |
We may contact you as part of a fundraising effort. We
may disclose health information to a foundation related
to us so that the foundation may contact you in raising
money for a specific cause such as breast cancer. We only
would release contact information, such as your name,
address and phone number, and the dates you received treatment
or services at our office. If you do not want us to contact
you for fundraising efforts, you must notify the Privacy
Officer in writing. |
| |
|
| Other
Uses |
| • |
Other
uses and disclosures, besides those identified in this
Notice, will be made only as otherwise required by law
or with your written authorization and you may revoke
the authorization as previously provided in this Notice
under "Your Health Information Rights." |
