Notice of Privacy Practices:
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.
If you have any questions about this notice, please
contact the Privacy Officer for the organization at 337-364-3301.
WHO WILL FOLLOW THIS NOTICE
This notice describes our practice and that of:
Any health care professional authorized to enter information into
your office chart;
- All departments and units of this practice to
ensure quality service and appropriate billing processes;
- Any member of a volunteer group we allow to help
you while you are in the organization;
- Any medical student, intern, resident or fellow
that we allow to help you while you are in the organization;
- Any representative of an insurance carrier, managed
care organization, clinical research organization, data analysis
organization, or quality improvement organization that is participating
in a review of your medical care;
- All employees, staff and other office personnel;
- All other entities, sites and locations where
the health care professionals in this practice follow the terms
of this notice. In addition, these entities, sites and locations
may share medical information with each other for treatment, payment
or operations purposes as described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health
is personal. We are committed to protecting your medical information.
We create a record of the care and services you receive at this
office. We 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 the office, whether
made by office personnel or your personal doctor.
This notice will tell you about the ways in which
we may use and disclose medical information about you. We also describe
your rights and certain obligations that we have regarding the use
and disclosure of medical information.
We are required by law to:
- Make sure that medical information that identifies
you is kept private;
- Give you this notice of our legal duties and
privacy practices with respect to medical information about you;
- Follow the terms of the notice that is currently
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION
The following categories describe different
ways that we use and disclose medical information. For each category
of uses or disclosures we will explain the meaning and try to give
some examples. Not every use or disclosure in a category will be
listed. However, all of the ways we are permitted to use and disclose
information will fall within one of the categories.
Treatment - We may use medical information about
you to provide you with medical treatment or services. We may disclose
medical information about you to doctors, nurses, technicians, medical
students, or other office personnel who are involved in taking care
of you at the office. For example, a doctor treating you for a broken
leg may need to know if you have diabetes because diabetes may slow
the healing process. In addition, the doctor may need to tell the
dietitian if you have diabetes so that we can arrange for you to
receive information regarding appropriate meals. Different departments
of the office also may share medical information about you in order
to coordinate the different things you need, such as prescriptions,
lab work and x-rays. We also may disclose medical information about
you to people outside the office who may be involved in your medical
care after you leave the office, such as family members, clergy
or others we use to provide services that are part of your care.
Payment - We may use and disclose medical information about you
so that the treatment and services you receive at the office, hospital,
ambulatory surgery center, nursing home or other site may be billed
to and payment may be collected from you, an insurance company or
a third party. For example, we may need to give your health plan
information about the services you received at the office, hospital
or ambulatory surgery center, so that your health plan will pay
us or reimburse you for the services. We may also tell your health
plan about a treatment you are going to receive to obtain prior
approval or to determine whether your plan will cover the treatment.
Health Care Operations - We may use and disclose
medical information about you for organizational operations. These
uses and disclosures are necessary in the regular course of business
to run the organization and make sure that all of our patients receive
quality care. For example, we may use medical information to review
our treatment and services and to evaluate the performance of our
staff in caring for you. We may also combine medical information
about many office patients to decide what additional services the
office should offer, what services are not needed, and whether certain
new treatments are effective. We may also disclose information to
doctors, nurses, technicians, medical students, and other office
personnel for review and learning purposes. We may also combine
the medical information we have with medical information from other
organizations to compare how we are doing and see where we can make
improvements in the care and services that we offer. We may remove
information that identifies you from this set of medical information
so others may use it to study health care and health care delivery
without learning who the specific patients are.
Appointment Reminders - We may use and disclose
medical information to contact you as a reminder that you have an
appointment for treatment or medical care at the office. We may
leave an appointment reminder on your answering machine or a message
with the person answering the phone at your residence listing only
your name, the appointment time and the name of this office.
Treatment Alternatives - We may use and disclose
medical information to tell you about or recommend possible treatment
options or alternatives that may be of interest to you.
Health-Related Benefits and Services - We may use
and disclose medical information to tell you about health-related
benefits or services that may be of interest to you.
Ambulatory Surgery Center Status Requests - We may
include certain limited information about you in the ambulatory
surgery directory while you are a patient at the ambulatory surgery
center. This information may include your name, location in the
ambulatory surgery center, your general condition (e.g., fair, stable,
etc.) and your religious affiliation. The directory information,
except for your religious affiliation, may also be released to people
who ask for you by name. Your religious affiliation may be given
to a member of the clergy, such as a priest or rabbi, even if they
don't ask for you by name. This is so your family, friends and clergy
can generally know how you are doing. If you would not like this
information to be disclosed please request in writing and submit
it to the organization's Privacy Officer.
Individuals Involved in Your Care or Payment for
Your Care - We may release medical information about you to a friend
or family member who is involved in your medical care. We may also
give information to someone who helps pay for your care. We may
also tell your family or friends your condition and that you are
in the hospital, ambulatory surgery center or office. In addition,
we may disclose medical information about you to an entity assisting
in a disaster relief effort so that your family can be notified
about your condition, status and location.
Future Communications: We may communicate to you
via newsletters, mail outs or other means regarding treatment options,
health related information, disease management programs, wellness
programs, or other community based initiatives or activities our
facility is participating in.
Research - Under certain circumstances, we may use
and disclose medical information about you for research purposes.
For example, a research project may involve comparing the health
and recovery of all patients who received one medication to those
who received another, for the same condition. All research projects,
however, are subject to a special approval process. This process
evaluates a proposed research project and its use of medical information,
trying to balance the research needs with patients' need for privacy
of their medical information. Before we use or disclose medical
information for research, the project will have been approved through
this research approval process. We may, however, disclose medical
information about you to people preparing to conduct a research
project, for example, to help them look for patients with specific
medical needs, so long as the medical information they review does
not leave the office. We will almost always ask for your specific
permission if the researcher will have access to your name, address
or other information that reveals who you are, or will be involved
in your care at the office.
As Required By Law - We will disclose medical information
about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety -
We may use and disclose medical information about you when necessary
to prevent a serious threat to your health and safety or the health
and safety of the public or another person. Any disclosure, however,
would only be to someone able to help prevent the threat.
Organ and Tissue Donation - If you are an organ donor, we may release
medical information to organizations that handle organ procurement
or organ, eye or tissue transplantation or to an organ donation
bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans - If you are a member of the
armed forces, we may release medical information about you as required
by military command authorities. We may also release medical information
about foreign military personnel to the appropriate foreign military
If you are a member of the Armed Forces, we may
disclose medical information about you to the Department of Veterans
Affairs upon your separation or discharge from military services.
This disclosure is necessary for the Department of Veterans Affairs
to determine whether you are eligible for certain benefits.
Workers' Compensation - We may release medical information
about you for workers' compensation or similar programs. These programs
provide benefits for work-related injuries or illness.
Public Health Risks - We may disclose medical information
about you for public health activities. These activities generally
include the following:
- To prevent or control disease, injury or disability;
- To report births and deaths;
- To report child abuse or neglect;
- To report reactions to medications or problems
- To notify people of recalls of products they
may be using;
- To notify a person who may have been exposed
to a disease or may be at risk for contracting or spreading a
disease or condition; and,
- To notify the appropriate government authority
if we believe a patient has been the victim of abuse, neglect
or domestic violence. We will only make this disclosure if you
agree or when required or authorized by law.
Health Oversight Activities - We may disclose medical
information to a health oversight agency for activities authorized
by law. These oversight activities include, for example, audits,
investigations, inspections, and licensure. These activities are
necessary for the government to monitor the health care system,
government programs, and compliance with civil rights laws.
Lawsuits and Disputes - If you are involved in a
lawsuit or a dispute, we may disclose medical information about
you in response to a court or administrative order. We may also
disclose medical information about you 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.
Law Enforcement - We may release medical information
if asked to do so by a law-enforcement official:
- In response to a court order, subpoena, warrant,
summons or similar process;
- To identify or locate a suspect, fugitive, material
witness, or missing person;
- About the victim of a crime if, under certain
limited circumstances, we are unable to obtain the person's agreement;
- About a death we believe may be the result of
- About criminal conduct at the office or ambulatory
surgery center; and
- In emergency circumstances to report a crime;
the location of the crime or victims; or the identity, description
or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors
- We may release medical 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 medical information
about patients to funeral directors as necessary to carry out their
National Security and Intelligence Activities -
We may release medical information about you to authorized federal
officials for intelligence, counterintelligence, and other national
security activities authorized by law.
Protective Services for the President and Others
- We may disclose medical information about you to authorized federal
officials so they may provide protection to the President, other
authorized persons or foreign heads of state or conduct special
Department of State - We may use medical information
about you to make decisions regarding your medical suitability for
a security clearance or service abroad. We may also release your
medical suitability determination to the officials in the Department
of State who need access to that information for these purposes.
Inmates - If you are an inmate of a correctional
institution or under the custody of a law enforcement official,
we may release medical information about you to the correctional
institution or law enforcement official. This release would be necessary
(1) for the institution to provide you with health care; (2) to
protect your health and safety or the health and safety of others;
or (3) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT
You have the following rights regarding
medical information we maintain about you:
Right to Inspect and Copy - You have the right to
inspect and copy medical information that may be used to make decisions
about your care. Usually, this includes medical and billing records,
but does not include psychotherapy notes.
To inspect and copy medical information that may
be used to make decisions about you, you must submit your request
in writing to the organization. You may give your written request
to the receptionist who will forward it to the Privacy Officer or
submit the request by mail. If you request a copy of the information,
we may charge a fee as permitted by state law for the costs of copying,
mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to medical information,
you may request that the denial be reviewed. Another licensed health
care professional chosen by the office will review your request
and the denial. The person conducting the review will not be the
person who denied your request. We will comply with the outcome
of the review.
Right to Amend - If you feel that medical information
we have about you is incorrect or incomplete, you may ask us to
amend the information.
You have the right to request an amendment for
as long as the information is kept by or for the office.
To request an amendment, your request must be made in writing and
submitted to the organization. In addition, you must provide a reason
that supports your request.
We may deny your request for an amendment if it
is not in writing or does not include a reason to support the request.
In addition, we may deny your request if you ask us to amend information
- Was not created by us, unless the person or entity
that created the information is no longer available to make the
- Is not part of the medical information kept by
or for the office;
- Is not part of the information which you would
be permitted to inspect and copy; or,
- Is accurate and complete.
Right to an Accounting of Disclosures - You have
the right to request an "accounting of disclosures." This
is a list of the disclosures we made of medical information about
To request this list or accounting of disclosures,
you must submit your request in writing. Your request cannot be
for services provided more than six years ago and may not include
dates before April 14, 2003. Your request should indicate in what
form you want the list (for example: on paper or electronically).
The first list you request within a 12-month period will be free.
For additional lists, we may charge you for the costs of providing
the list. We will notify you of the cost involved and you may choose
to withdraw or modify your request at that time before any costs
Right to Request Restrictions - You have the right
to request a restriction or limitation on the medical information
we use or disclose about you for treatment, payment or health care
operations. You also have the right to request a limit on the medical
information we disclose about you to someone who is involved in
your care or the payment for your care, like a family member or
friend. For example, you could ask that we not use or disclose information
about a surgery that you had.
We are not required to agree to your request. If
we do agree, we will comply with your request unless the information
is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing.
In your request, you must tell us (1) what information you want
to limit; (2) whether you want to limit our use, disclosure or both;
and (3) to whom you want the limits to apply, for example, disclosures
to your spouse.
Right to Request Confidential Communications - You
have the right to request that we communicate with you about medical
matters in a certain way or at a certain location. For example,
you can ask that we only contact you at work or by mail.
To request confidential communications, you must
make your request in writing. We will not ask you the reason for
your request. We will accommodate all reasonable requests. Your
request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice - You have
the right to a paper copy of this notice. You may ask us to give
you a copy of this notice at any time. Even if you have agreed to
receive this notice electronically, you are still entitled to a
paper copy of this notice.
You may obtain a copy of this notice at our web
To obtain a paper copy of this notice, contact
the organization's Privacy Officer at 364-3301, then please ask
the receptionist to transfer you, or request a copy by mail.
CHANGES TO THIS NOTICE
We reserve the right to change this notice.
We reserve the right to make the revised or changed notice effective
for medical information we already have about you as well as any
information we receive in the future. We will post a copy of the
current notice in the office. The notice will contain on the first
page, in the top right-hand corner, the effective date. In addition,
each time you register at or are seen at the office for treatment
or health care services as an outpatient, we will offer you a copy
of the current notice in effect.
If you believe your privacy rights have
been violated, you may file a complaint with the office or with
the Secretary of the Department of Health and Human Services. To
file a complaint with the office, contact the organization's Privacy
Officer at 364-3301 and ask the receptionist to transfer you or
file a complaint by mai. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical
information not covered by this notice or the laws that apply to
us will be made only with your written permission. If you provide
us permission to use or disclose medical information about you,
you may revoke that permission, in writing, at any time. If you
revoke your permission, we will no longer use or disclose medical
information about you for the reasons covered by your written authorization.
You understand that we are unable to take back any disclosures we
have already made with your permission, and that we are required
to retain our records of the care that we provided to you.