Privacy Practices

Notice of Privacy Practices for Protected Health Information HIPAA Revision 10.350

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAYBE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Understanding Your Health RecordJInformation

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• basis for planning your care and treatment
• means of communication among the many health professionals who contribute to your care
• legal document describing the care you received
• means by which a third-party payer can verify that services billed were actually provided
• a tool in educating health professionals
• a source of data for medical research
• a source of information for public health officials charged with improving the health of the nation
• a source of data for facility planning and marketing
• a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to:

• ensure its accuracy
• better understand who, what, when, where, and why others may access your health information
• make more informed decisions when authorizing disclosure to others

Your Health Information Rights

Although your health record is the physical property of The Kaufmann Clinic, Inc., the information belongs to you. You have the:

• right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care. You must submit a written request to the Kaufmann Clinic's designated privacy official in order to inspect and/or copy your health information. If you require a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We have the right to deny your request and/or copy in certain limited circumstances. You may ask that your denial be reviewed, which, in most cases is handled by an outside licensed healthcare professional. We will comply with the outcome of the review.
• right to amend your healthcare information if you believe the information is incorrect or incomplete. You have the right to request an amendment as long as your healthcare information is kept by this office. To request an amendment, complete and submit a Medical Record/Correction Form to the Kaufmann Clinic's designated privacy official. This request may be denied if it is not in writing or does not include a reason to support the request, such as the information is accurate and complete, is not part of the health information that we keep, or that the person creating the information is no longer available to make the amendment.
• right to request restrictions or limitations on the health information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request if we feel the information is needed to provide you emergency treatment.
• right to request confidential communications 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 may complete and submit the Request for Restriction on Use/Disclosure of Medical Information to Kaufmann Clinic's privacy official.

The Kaufmann Clinic's Responsibilities

The Kaufmann Clinic is required to:

• maintain the privacy of your health information
• provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• abide by the terms of this notice
• notify you if we are unable to agree to a requested restriction
• accommodate reasonable request you may have to communicate health information by alternative means or at alternate locations

The Kaufmann Clinic reserves the right to change our practices and to make new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have supplied to us.

The Kaufmann Clinic will not use or disclose your health information without your authorization, except as described in this notice.

Examples of Disclosures for Treatment, Payment and Health Operations

The Kaufmann Clinic will use your health information for treatment.

For example: Information obtained by a nurse, physician, or othe_ member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record the actions taken and observations in how you respond to your treatment.

If your treatment requires you seeing another physician or health care provider, we will provide copies of your record that should assist them in providing you treatment.

The Kaufmann Clinic will use your health information for payment.

For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, or supplies used.

The Kaufmann Clinic will use your health information for regular health operations.

For example: Information in your health record may be provided to Business Associates such as physicians in the emergency department, radiology, outside reference laboratories, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information so that they can perform the job we have asked them to do and bill you or your third-party payer for the services rendered. To protect your health information, however, we require the Business Associate to appropriately safeguard your information.

Notification and Communication with family: We may use or disclose information to notify or assist a family member, personal representative, or another person responsible for your care, your location, and general condition. We may, using our best judgment, 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 payment related to your care.

Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Correctional Institutions: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Other Uses and Disclosures of Health Information

We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. If you give us this Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization ( different than the Authorization and Consent mentioned above) from you. In order to disclose these types of records for purposes of treatment, payment or healthcare operations, we will have to have both your Consent and a special written Authorization that complies with the law governing HIV or substance abuse records.

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Effective Date: April 14,2003

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• HIPAA Notice-of-Privacy-Practices