PREVENTIVE
MEDICINE PC
NOTICE OF PRIVACY PRACTICES
For Preventive Medicine, PC
212 W Edison Road, Suite B Mishawaka Indiana 46545
574-254-1400
1290 E. Ireland Road, Suite U200, South Bend Indiana 46614
574-231-1400
548 N. Oak Road, Plymouth Indiana 46563 574-935-3700
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 our Privacy
Contact or any staff member in our office.
Our Privacy Contact is Carrie Hannon.
This Notice of Privacy Practices describes how we may use and
disclose your protected health information to carry out your treatment,
collect payment for your care and manage the operations of this clinic.
It also describes our policies concerning the use and disclosure of this
information for other purposes that are permitted or required by law.
It also describes your rights to access and control your protected
health information. “Protected health information” is information about
you, including demographic information that may identify you, that
relates to your past, present or future physical or mental health or
condition and related health care services.
We are required by federal law to abide by the terms of this Notice
of Privacy Practices. We may change the terms of our notice, at any
time. The new notice will be effective for all protected health
information that we maintain at that time. You may obtain revisions to
our Notice of Privacy Practices by accessing our website
www.preventivemedicinepc.com
calling the office and requesting that a revised copy be sent to you in
the mail or asking for one at the time of your next appointment.
1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information Based Upon
Your Implied Consent
By applying to be treated in our office, you are implying consent
to the use and disclosure of your protected health information by your
physician, our office staff and others outside of our office that are
involved in your care and treatment for the purpose of providing health
care services to you. Your protected health information may also be
used and disclosed to bill for your health care and to support the
operation of the physician’s practice.
Following are examples of the types of uses and disclosures of your
protected health care information we will make, based on this implied
consent. These examples are not meant to be exhaustive but to describe
the types of uses and disclosures that may be made by our office.
Treatment: We will use and disclose your protected health information to
provide, coordinate, or manage your health care and any related
services. This includes the coordination or management of your health
care with a third party that has already obtained your permission to
have access to your protected health information. For example, we would
disclose your protected health information, as necessary, to another
physician who may be treating you. Your protected health information
may be provided to a physician to whom you have been referred to ensure
that the physician has the necessary information to diagnose or treat
you.
In addition, we may disclose
your protected health information from time-to-time to another physician
or health care provider (e.g., a specialist or laboratory) who, at the
request of your physician, becomes involved in your care by providing
assistance with your health care diagnosis or treatment to your
physician.
Payment: Your protected health information will be used, as needed, to
obtain payment for your health care services. This may include certain
activities that your health insurance plan may undertake before it
approves or pays for the health care services we recommend for you such
as; making a determination of eligibility or coverage for insurance
benefits, reviewing services provided to you for medical necessity, and
undertaking utilization review activities. For example, obtaining
approval for chiropractic spinal adjustments may require that your
relevant protected health information be disclosed to the health plan to
obtain approval for those services.
Healthcare Operations: We may use or disclose, as
needed, your protected health information in order to support the
business activities of your physician’s practice. These activities
include, but are not limited to, quality assessment activities, employee
review activities and training of chiropractic students.
For example, we may disclose your protected health information to
chiropractic interns or precepts that see patients at our office.
Communications between you and the doctor or his assistants may be
recorded to assist us in accurately capturing your responses. We may
also call you by name in the waiting room when your physician is ready
to see you. We may use or disclose your protected health information,
as necessary, to contact you to remind you of your appointment.
We will share your protected health information with third party
“business associates” that perform various activities (e.g., billing,
transcription services) for the practice. Whenever an arrangement
between our office and a business associate involves the use or
disclosure of your protected health information, we will have a written
contract with that business associate that contains terms that will
protect the privacy of your protected health information.
We may use or disclose your protected health information, as
necessary, to provide you with information about treatment alternatives
or other health-related benefits and services that may be of interest to
you. We may also use and disclose your protected health information for
other marketing activities. For example, your name and address may be
used to send you a newsletter about our practice and the services we
offer. We may also send you information about products or services that
we believe may be beneficial to you. You may contact our Privacy
Contact to request that these materials not be sent to you.
Uses and Disclosures of
Protected Health Information That May Be Made With Your Written
Authorization
Other uses and disclosures of your protected health information
will be made only with your written authorization, unless
otherwise permitted or required by law as described below.
For Example, with your written, signed authorization, we may use
your demographic information and the dates that you received treatment
from your physician, as necessary, in order to contact you for
fundraising activities supported by our office. With your written,
signed authorization, we may use your photograph on a “Birthday Board”
or other display in our waiting room or your testimonial story in a
folder kept in the waiting room for patient education purposes.
You may revoke any of these authorizations, at any time, in
writing, except to the extent that your physician or the physician’s
practice has taken an action in reliance on the use or disclosure
indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made
With Your Authorization or Opportunity to Object
In the following instance where we may use and disclose your
protected health information, you have the opportunity to agree or
object to the use or disclosure of all or part of your protected health
information. If you are not present or able to agree or object to the
use or disclosure of the protected health information, then your
physician may, using professional judgment, determine whether the
disclosure is in your best interest. In this case, only the protected
health information that is relevant to your health care will be
disclosed.
Others Involved in Your Healthcare:
Unless you object, we may disclose to a member of your family, a
relative, a close friend or any other person you identify, your
protected health information that directly relates to that person’s
involvement in your health care. If you are unable to agree or object
to such a disclosure, we may disclose such information as necessary if
we determine that it is in your best interest based on our professional
judgment. We may use or disclose protected health information to notify
or assist in notifying a family member, personal representative or any
other person that is responsible for your care of your location, general
condition or death. Finally, we may use or disclose your protected
health information to an authorized public or private entity to assist
in disaster relief efforts and to coordinate uses and disclosures to
family or other individuals involved in your health care.
Other Permitted and Required Uses and Disclosures That May Be Made
Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your protected health information in the
following situations without your consent or authorization. These
situations include:
Required By Law: We may use or disclose your protected health information to the
extent that the use or disclosure is required by law. The use or
disclosure will be made in compliance with the law and will be limited
to the relevant requirements of the law. You will be notified, as
required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public
health activities and purposes to a public health authority that is
permitted by law to collect or receive the information. The disclosure
will be made for the purpose of controlling disease, injury or
disability. We may also disclose your protected health information, if
directed by the public health authority, to a foreign government agency
that is collaborating with the public health authority.
Communicable Diseases: We may disclose your
protected health information, if authorized by law, to a person who may
have been exposed to a communicable disease or may otherwise be at risk
of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight
agency for activities authorized by law, such as audits, investigations,
and inspections. Oversight agencies seeking this information include
government agencies that oversee the health care system, government
benefit programs, other government regulatory programs and civil rights
laws.
Abuse or Neglect: We may disclose your protected health information to a public
health authority that is authorized by law to receive reports of child
abuse or neglect. In addition, we may disclose your protected health
information if we believe that you have been a victim of abuse, neglect
or domestic violence to the governmental entity or agency authorized to
receive such information. In this case, the disclosure will be made
consistent with the requirements of applicable federal and state laws.
Food and Drug Administration:
We may disclose your protected health information to a person or company
required by the Food and Drug Administration to report adverse events,
product defects or problems, biologic product deviations, track
products; to enable product recalls; to make repairs or replacements, or
to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any
judicial or administrative proceeding, in response to an order of a
court or administrative tribunal (to the extent such disclosure is
expressly authorized), in certain conditions in response to a subpoena,
discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as
applicable legal requirements are met, for law enforcement purposes.
These law enforcement purposes include (1) legal processes and otherwise
required by law, (2) limited information requests for identification and
location purposes, (3) pertaining to victims of a crime, (4) suspicion
that death has occurred as a result of criminal conduct, (5) in the
event that a crime occurs on the premises of the practice, and (6)
medical emergency (not on the Practice’s premises) and it is likely that
a crime has occurred.
Coroners, Funeral Directors, and Organ Donation:
We may disclose protected health information to a coroner or medical
examiner for identification purposes, determining cause of death or for
the coroner or medical examiner to perform other duties authorized by
law. We may also disclose protected health information to a funeral
director, as authorized by law, in order to permit the funeral director
to carry out their duties. We may disclose such information in
reasonable anticipation of death. Protected health information may be
used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: We may disclose your protected health information to researchers
when an institutional review board has approved their research and that
review board has reviewed the research proposal and established
protocols to ensure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose
your protected health information, if we believe that the use or
disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public. We may also
disclose protected health information if it is necessary for law
enforcement authorities to identify or apprehend an individual.
Military Activity and National Security:
When the appropriate conditions apply, we may use or disclose protected
health information of individuals who are Armed Forces personnel (1) for
activities deemed necessary by appropriate military command authorities;
(2) for the purpose of a determination by the Department of Veterans
Affairs of your eligibility for benefits, or (3) to foreign military
authority if you are a member of that foreign military services. We may
also disclose your protected health information to authorized federal
officials for conducting national security and intelligence activities,
including for the provision of protective services to the President or
others legally authorized.
Workers’ Compensation: We may disclose your
protected health information, as authorized, to comply with workers’
compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you
are an inmate of a correctional facility and your physician created or
received your protected health information in the course of providing
care to you.
Required Uses and Disclosures:
Under the law, we must make disclosures to you and when required by the
Secretary of the Department of Health and Human Services to investigate
or determine our compliance with the requirements of Section 164.500 et.
seq.
2. Your Rights
Following is a statement of your rights with respect to your
protected health information and a brief description of how you may
exercise these rights.
You have the right to inspect and copy your protected health
information. This means you may inspect and obtain a copy of protected health
information about you that is contained in a designated record set for
as long as we maintain the protected health information. A “designated
record set” contains medical and billing records and any other records
that your physician and the practice uses for making decisions about
you.
Under federal law, however, you may not inspect or copy the
following records; psychotherapy notes; information compiled in
reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding, and protected health information
that is subject to law that prohibits access to protected health
information. Depending on the circumstances, a decision to deny access
may be reviewable. In some circumstances, you may have a right to have
this decision reviewed. Please contact our Privacy Contact if you have
questions about access to your medical record.
You have the right to request a restriction of your protected
health information. This means you may ask us not to use or disclose any part of your
protected health information for the purposes of treatment, payment or
healthcare operations. You may also request that any part of your
protected health information not be disclosed to family members or
friends who may be involved in your care or for notification purposes as
described in this Notice of Privacy Practices. Your request must be in
writing and state the specific restriction requested and to whom you
want the restriction to apply.
Your physician is not required to agree to a restriction that you
may request. If physician believes it is in your best interest to
permit use and disclosure of your protected health information, your
protected health information will not be restricted. If your physician
does agree to the requested restriction, we may not use or disclose your
protected health information in violation of that restriction unless it
is needed to provide emergency treatment. With this in mind, please
discuss any restriction you wish to request with your physician. You
may request a restriction by presenting your request, in writing to the
staff member identified as “Privacy Contact” at the top of this form. A
simple sentence, “Do not use my PHI (Protected Health Information) for
education of Chiropractic Students.” or “Do not send any communications
to my home address.” Sign and date your request. Ask that the staff
provide you with a photocopy of your request initialed by them. This
copy will serve as your receipt.
You have the right to request to receive confidential
communications from us by alternative means or at an alternative
location.
We will accommodate reasonable requests. We may also condition this
accommodation by asking you for information as to how payment will be
handled or specification of an alternative address or other method of
contact. We will not request an explanation from you as to the basis
for the request. Please make this request in writing to our Privacy
Contact.
You may have the right to have your physician amend your protected
health information. This means you may request an amendment of protected health
information about you in a designated record set for as long as we
maintain this information. In certain cases, we may deny your request
for an amendment. If we deny your request for amendment, you have the
right to file a statement of disagreement with us and we may prepare a
rebuttal to your statement and will provide you with a copy of any such
rebuttal. Please contact our Privacy Contact to determine if you have
questions about amending your medical record.
You have the right to receive an accounting of certain disclosures
we have made, if any, of your protected health information.
This right applies to disclosures for purposes other than treatment,
payment or healthcare operations as described in this Notice of Privacy
Practices. It excludes disclosures we may have made to you, for a
facility directory, to family members or friends involved in your care,
pursuant to a duly executed authorization or for notification purposes.
You have the right to receive specific information regarding these
disclosures that occurred after April 14, 2003. You may request a
shorter timeframe. The right to receive this information is subject to
certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us,
upon request, even if you have agreed to accept this notice
electronically.
3. Complaints
You may complain to us or to the Secretary of Health and Human
Services if you believe your privacy rights have been violated by us.
You may file a complaint with us by notifying our privacy contact of
your complaint. We will not retaliate against you for filing a
complaint.
Our Privacy Contact is
Carrie Hannon You may contact our Privacy Contact, or any
staff member, including your physician at 574-254-1400 or
www.preventivemedicinepc.com for further information about the
complaint process.
This notice was published and becomes effective on
July
28, 2010