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Our Policy on Medical Record Privacy
This Notice describes the way our practice will treat medical
records and other health information that we have regarding
your medical care. We are required to keep records for each
of our patients in order to keep a record of your care, including
your diagnosis, treatment, services you receive, and other information.
We are required by law to protect your personal medical record
by keeping it private and following certain rules that dictate
whether and when we can use or disclose your information.
This Notice informs you of the ways we may use and disclose
your health information. It also notifies you of your rights
and our obligations in our use and disclosure of your health
information.
The law requires us to keep your health information private.
We are also required to give you this Notice. You have the right
to request additional copies of this Notice at any time by contacting
the Privacy Officer identified below.
We reserve the right to change this Notice. We reserve the right
to apply those changes to health information we currently have,
as well as information we may receive in the future. If we change
this Notice, you may request a new copy of the Notice at any
time by contacting the Privacy Officer identified below. We
will also keep a current copy of the Notice on display in our
office. We are required to follow the terms of the Notice that
is currently in effect.
How we may Use and Disclose
Your Health Information
We may use and disclose your health information for a number
of purposes in connection with your medical care and in running
our practice. The following lists a number of typical uses
and disclosures within our practice, with explanations to
help you understand your rights. You will not be asked to
separately authorize us to do these things.
1. Treatment.
We may use your health information to provide you with medical
treatment. For example, we may use your health information
to diagnose your illness or injury, provide you with services,
or refer you to another physician. We may disclose your health
information to doctors, nurses, technicians, medical students,
or other personnel who are involved in your care. We may also
disclose your health information to people outside of our
medical practice who may be involved in your medical care,
such as family members, clergy or others.
2. Payment.
We may use and disclose your health information to your health
plan, insurance company, HMO, or other third party in order
to bill and collect for services provided to you. For example,
we may give your health plan information regarding your diagnosis
and treatment in order to be paid for your x-rays or diagnostic
tests. We may also provide information to determine whether
your health plan pays for the medical care you need, and whether
we need to get authorization from the health plan before treating
you.
3. Health Care Operations.
We may use and disclose your health information in the process
of running our medical practice. For example, we may use or
disclose your information if we conduct quality assessment
and improvement activities to ensure that our patients receive
top quality medical care. We may also use or disclose your
information in training and evaluation of our physicians and
other staff, or as part of a medical review, audit, or legal
activities.
4. Appointment Reminders.
We may use and disclose your health information to contact
you as a reminder that you have an appointment with our practice
or to schedule an appointment.
5. Treatment Alternatives.
We may use and disclose your health information to tell you
about or recommend treatment alternatives or health-related
benefits and services that may be of interest to you.
6. Individuals Involved in Your Care or Payment for
Your Care.
We may disclose your health information to a family member
or friend who is involved in your medical care, or who helps
pay for your care. In addition, we may disclose your health
information in the event of a disaster relief effort, so that
your family can be notified about your condition, status,
and location.
7. Required By Law.
We will disclose your health information when we are required
to do so by federal, state, or local law.
8. Public Health Risks.
We may disclose your health information for public health
activities, such as reporting disease, injury or disability;
births and deaths; child abuse or neglect; defects, recalls,
or problems with drugs, medical devices, or other products;
to prevent or control disease, injury or disability; exposure
to or risk for diseases or conditions. We may also notify
authorities if we believe you have been the victim of abuse,
neglect, or domestic violence, if we are required or permitted
by law to do so, or if you agree to the notification.
9. Health Oversight Activities.
We may disclose health information to a health oversight agency
authorized by law for audits, investigations, inspections,
and licensure. Health oversight agencies generally oversee
the health care system, government health programs (such as
Medicare and Medicaid), and the enforcement of civil rights
laws.
10. Judicial and Administrative Proceedings.
We may disclose your health information in response to a court
order or administrative order. We may also disclose your health
information to respond to a subpoena, discovery request, or
other request that is not issued by a judge or administrator,
but only if efforts have been made to inform you of the request
or to get a protective order for the information.
11. Law Enforcement.
We may release health information if asked to do so by a law
enforcement official under the following circumstances:
· If you have incurred certain injuries or wounds
that are legally required to be reported;
· In response to a court order, subpoena, warrant,
summons, investigative demand, 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;
· About a suspicious death that we believe may be
the result of criminal conduct;
· About criminal conduct on our premises; and
· In emergency circumstances to report a crime, its
location, or information about the person who may have committed
the crime.
12. Coroners, Medical Examiners, and Funeral Directors.
We may disclose your health information to a coroner or medical
examiner. This may be necessary, for example, to identify
or determine the cause of death of a deceased person, or as
otherwise required by law. We may also disclose health information
to funeral directors as necessary to carry out their duties.
13. Organ and Tissue Donation.
We may use or disclose your health information to organizations
that handle organ procurement to facilitate organ or tissue
donation and transplantation.
14. To Avert a Serious Threat to Health or Safety.
We may use and disclose your health information when necessary
to prevent or lessen a serious threat to the health and safety
of you, the public, or another person. Any disclosure would
be made to law enforcement or someone else who can help prevent
or lessen the threat.
15. Research.
We may use and disclose your health information for medical
research if an Institutional Review Board or similar body
approves the use and disclosure without your authorization,
or if the use and disclosure is solely for purposes preparatory
to research, such as preparing a research protocol, or if
the use and disclosure is solely for research on individuals
who are deceased.
16. Specialized Government Functions.
We may use or disclose your health information for military
command authorities, upon your separation or discharge from
military service, to authorized officials. We may also disclose
your health information to the appropriate government officials
when it is necessary to conduct intelligence or other national
security activities authorized by federal law. In addition,
we may release your health information if it relates to protection
of the President of the United States or foreign heads of
state. Finally, we may disclose certain information related
to members of the armed services and foreign military services
to the appropriate personnel.
17. Inmates.
If you are an inmate of a correctional facility or under the
custody of a law enforcement official, we may disclose your
health information to the correctional institution or law
enforcement official in order to provide you with medical
services, protect you or others, or to ensure the safety of
the correctional facility.
18. Workers' Compensation.
We may disclose your health information in relation to workers'
compensation or similar program established by law that provides
benefits for work-related illness or injuries. We may also
disclose your health information to your employer if the health
care services we provide to you are at the request of your
employer in order to carry out work-place medical surveillance,
but only if we notify you first.
Your Rights Regarding
Your Health Information
1. Your Right to Restrict our Activities.
You have the right to request that we restrict the use or disclosure
of your health information for treatment, payment, or healthcare
operations (as described above). You may also restrict us from
disclosing your health information to family members or friends.
For example, you may request that we limit what information
we provide to your family members regarding diagnostic tests
you may have had.
We are not required to agree to your request.
If we agree to your restrictions or limitations, we will comply
with your wishes unless the information is needed to provide
emergency treatment to you. To request restrictions or limitations,
you must make a written request to the Privacy Officer identified
below. In your written request, you must tell us (1) what information
you want to limit; (2) whether you want to limit use of the
information and/or disclosure of the information; and (3) to
whom the limitations or restrictions will apply (for example,
disclosures to your spouse).
2. Your Right to Request Confidential Communications.
You have the right to tell us how you would like us to communicate
with you. For example, you may ask that we call you at a certain
phone number, or you may tell us whether we may leave a message
for you.
To request confidential communications, you must make your request
in writing to the Privacy Officer listed below. Your request
must specify how or where you wish to be contacted. We will
follow all reasonable requests for confidential communications.
3. Your Right to Inspect and Copy.
You have the right to inspect and copy your health information,
including most of your medical and billing records. You do not
have the right to review any psychotherapy notes, information
created for use in legal actions, or other information covered
by certain laws.
If you would like to inspect and/or copy your health information,
you must submit your request in writing to the Privacy Officer
listed below. If you request a copy of the information, we may
charge you a reasonable fee for copying, postage, or other expenses
related to your request.
We may deny your request to inspect and/or copy your health
information. If we do, you may request that the denial be reviewed.
We will then choose a licensed health care professional to 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.
4. Your Right to Amend.
If you feel that your health information is incorrect or incomplete,
you may ask us to amend your records. To request an amendment,
you must submit a written request to the Privacy Officer identified
below. Your request must state the reason you believe an amendment
is necessary.
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: (a) we did not create the information
(unless the entity that created the information is no longer
available); the information is not in our possession or control;
(c) you would not be permitted to inspect or copy the information;
or (d) the information is accurate and complete.
5. Your Right to an Accounting of Disclosures.
You have the right to request an "accounting of disclosures."
This is a list of certain disclosures of your health information
that we have made.
To request this list of disclosures, you must submit a written
request to the Privacy Officer identified below. Your request
must state a time period for which the accounting is requested.
The time period may not be longer than six years and may not
include dates before April 14, 2003. You will receive one list
per year without charge. We may charge you for the costs of
providing additional lists within one year after your first
request. We will notify you of the cost involved and you may
choose to withdraw or modify your request if you do not wish
to pay the cost.
6. Your Right to Receive a Paper Copy of this Notice.
If you are receiving this notice electronically, you have the
right to request a paper copy of this notice by making a request
to the Privacy Officer identified below.
Changes to this notice
We reserve the right to change this notice, and to apply the
revisions or changes notice to health information we already
have about you, in addition to information we create or receive
in the future.
Complaints
If you believe your privacy rights have been violated, you may
file a complaint with the Privacy Officer identified below.
You may also file a complaint with the United States Secretary
of the Department of Health and Human Services at 200 Independence
Ave. S.W. Room 509F HHH Building Washington DC 20201. We encourage
your feedback regarding our privacy policies, and we will not
retaliate against you in any way if you file a complaint.
Other Uses of Your Health Information
This notice only describes the ways we may use and disclose
your health information without obtaining further permission
from you. There may be other reasons we may request to use or
disclose your health information. If we need to do so, we are
required to get your written authorization. If you grant us
this further authorization, you may revoke it at any time by
giving us written notice that you no longer authorize us to
use or disclose your health information for those purposes.
Other uses and disclosures of health 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 your health information, you may revoke that
permission, in writing, at any time. If you revoke your permission,
we will no longer use or disclose your health information 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.
Contact Information
For questions regarding this notice, or to receive further information,
please contact the Privacy Officer at:
Leonard J. Strzelecki, Privacy Officer
XRC Medical Imaging and X-Ray Consultants, Inc.
121 S. St. Louis Blvd.
South Bend, IN 46617
Phone: 574-233-3123 Ext. 21
Fax: 574-233-4135
Email: Strzelecki@xrcmi.com
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