PENINSULA ORTHOPAEDIC ASSOCIATES, P.A.
Notice to Patients of Privacy Practices
This notice describes how medical information about you may be used and
disclosed. We are required by law to protect the privacy of your protected
health information. This document also explains how you can gain access to
your medical information and who to contact should you have any complaint.
Please read this document carefully and sign the form to acknowledge you
have received this notice.
A. The general consent for release of medical
records you sign authorizes Peninsula Orthopaedic Associates to disclose
the information in your medical record for treatment, payment, and health
care operations:
- For the purpose of providing, coordinating, or managing your
treatment and related services. Your information may be shared with
employees and contractors of the provider, or with other health care
providers who are treating you or consulting in your care.
- For the purpose of arranging payment for your care. Your information
may be shared with your insurer or other third party payor who is
responsible for paying all or part of the cost for your care. This may
include certain activities your health insurance plan or workers
compensation insurer requires before it approves or pays for health care
services we recommend.
- For the purpose of health care operations. We may use and disclose
information that is necessary for our business operations, e.g.,
internal quality assessments, contacting other health care providers
about treatment alternatives. We may use information about you to remind
you by telephone, letter, or postcard of an appointment for treatment of
medical care or to notify you of a diagnostic test result.
B. You may be asked to sign a specific
authorization for release of medical records, which will authorize us to
make a specific disclosure that is not covered under section A above. The
specific information, the entity to whom it will be disclosed, and the
purpose for which it will be used will be documented for your review
before signing.
C. You may revoke any consent or authorization
provided to us by giving a written notice of revocation.
D. We may be required by law to disclose your
records that you have not authorized. Examples of these situations include
but are not limited to, complying with workers compensation laws,
receiving a subpoena for the records, or if public responsibility requires
disclosure, e.g., to protect public health. We will keep all disclosures
of your medical records to the minimum necessary.
E. Your rights regarding health information
about you:
- You have the right to inspect a copy your health information.
- If you feel that the health information we have about you is
incomplete or inaccurate, you have the right to request an amendment to
your medical records. The request must be made in writing with the
reason that supports your request. If we do not agree with your request,
you have the right to ask that your statement be place in the medical
record.
- You have the right to find out how your health information is used
and to whom it is disclosed. You may request an accounting of your
medical record disclosures made by us except for disclosures made for
treatment, payment, and health care operations covered in Section A.
F. We are required by law to maintain the
privacy of your protected health information and if you believe that your
rights have been violated, you may complain to the Secretary of the U.S.
Department of Health and Human Services or complain to us by talking to
us, calling us, or writing to us with details. Please ask to speak to or
contact our privacy complaints contact person, Susan Calhoun, at our
office. We will not retaliate in any way against a patient for making a
complaint.
G. We reserve the right to change our privacy
practices and to make new policies effective for all protected health
information that we maintain. If we should do so, we will issue an updated
"notice to patients" to all of our patients.
Form Date 04/14/03 |