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
- This is a formal notification, as required
by CMS (Centers for Medicare and Medicaid Services) concerning
that all patients and staff understand the importance of guarding
- This practice has a legal obligation
to maintain all medical records and information in the strictest
of confidence as required by law. What this means to the patient is that we must
safeguard patient information. This means we cannot release
information to others without your written consent, including
conversations, reminder calls, test results and other information
that may be of a confidential nature. Patient information
about health care is identified as “PHI” or Protected Health Information.
- Your protected health information (PHI)
is an intricate part of your medical care, and can be used or
disclosed with your written consent as follows:
- For your treatment in this practice and other locations under
the physician’s immediate care. This may include any referral
for services such as lab, x-rays, other diagnostic testing or
treatment related to your condition or medical care needs. This
may also include conversations with other physicians.
- For obtaining payment for treatment
with your identified insurance or health coverage program. This would include any documentation
related to this process, which may include history forms, progress
notes or operative notes. This would include eligibility
verification, prior authorization and claim submission.
- For operations of this practice, such as enrolling with insurance
programs, hospital privileges, accounting and compliance with
federal and state laws and regulations.
- Appointment reminders and health related benefit services only with
your consent identified on the registration form
- Disclosure to your family and friends concerning any related
health care information with your consent on the registration
form which can be modified at any time orally, followed by written
- Consent is not required for emergency
care and treatment. An
emergency is identified as a medical condition that in the judgment
of the physician or medical entity required immediate and full
information for care on your behalf.
- Certain disclosures can be
made without your consent, and they are as follows:
required by the government or law enforcement agencies. Specific
areas that require release include gun shot wounds, domestic
violence, and victims of abuse or neglect.
- Information used for public health purposes, medical examiners
or related to a person’s death or for the health department for
- Information used for health care oversight, such as a site
review by an insurance program.
- Information related to organ donation.
- Information related to certain research procedures, the majority
of this information is stripped of any personal data, and is
normally generic (age, sex, diagnosis) in nature.
- Information provided to avoid harm if there is a threat to
patient or other safety.
- Specific governmental functions.
- Workers compensation review.
Your rights with respect to your protected health information.
- The right to request limits on the uses and disclosure at registration
or any time during your care.
- The right to choose how we send this information to you, including
an alternate address.
- The right to see and obtain copies of
this information, but there may be copy and postage fees.
- The right to get a listing of who we have made disclosures
to about your PHI.
- The right to correct and update your file
through an amendment process if appropriate.
This practice reserves the right to
modify or change this Privacy Statement and process at any
time. Revision to the Notice
will be available upon request by contacting the office. The
changes will be effective retroactively to the initial date of
the Privacy Notice. An updated Privacy Notice will be posted
in the office within 60 days of the revision.
If you have a concern or complaint about how your protected
health information is being used, from this time forward you
should first contact our office to see if we can resolve your
concerns or you may contact the Office of Civil Rights or the
Ohio Medicare Carrier, GBA Palmetto.
|Contact the office manager and complete a complaint form for
review and discussion.
Columbia Road, Suite 111, Westlake, OH 44145
If you are not satisfied with this response, you may report
the practice to:
Office of Civil Rights
Department of Health & Human Services
233 N. Michigan Avenue, Suite 240
Chicago, Illinois 60601
the local Medicare Part B Intermediary
B Operations – HIPAA Compliance Concern
This privacy plan is a working draft, which became effective November
|Patient Signature on receipt of Privacy
|Patient unable to sign due to
|Patient refused to sign – witness
(Copy maintained in chart)