Plastic Surgery Associates of NEA

DR. CONNIE HIERS

Notice of Privacy Practices for Protected Health Information

 

 

 

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 consent, the office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations.  Protected health information is the information we create and obtain in providing our services to you.  Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment.  It also includes billing documents for those services.

 

Examples of Uses of Your Health Information for treatment purposes are:

·  During the course of your treatment, the physician determines he/she will need to consult with another

     specialist in the area.  He/she will share the information with such specialist and obtain his/her input.

 

Example of Use of Your Health Information for payment purposes:

·   We submit requests for payment to your health insurance company.  The health insurance company or

     business associate helping us obtain payment requests information from us regarding your medical 

     care given.  We will provide information to them about you and the care given.

 

Example of Use of Your Information for Health Care Operations:  

·   We may obtain services from business associates such as quality assessment, quality improvement, out-

     come evaluation, protocol and clinical guidelines development, training programs, credentialing,

     medical review, legal services, and insurance.  We will share information about you with such

     business associates as necessary to obtain these services.    

 

Your Health Information Rights

 

The health and billing records we maintain are the physical property of the doctor’s office.

You have the following rights with respect to your Protected Health Information

 

    1.  Request a restriction on certain uses and disclosures of your health information by delivering the

         request in writing to our office---we are not required to grant the request but we will comply with

         any request granted;

 

    2.  Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information (“Notice”)

         by making a request at our office;

 

    3.  Right to inspect and copy your health record and billing record---you may excise this right by

         delivering the request in writing to our office using the form we provide to you upon request; appeal

         a denial of access to your protected health information except in certain circumstances;

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   4.   Right to request that your health care record be amended to correct incomplete or incorrect

         information by delivering a written request to our office using the form we provide to you upon

         request.  (The  physician or other health care provider is not required to make such amendments);

         you may file a statement of disagreement if your amendment is denied, and require that the request

         for amendment and any denial by attached in all future disclosures of your protected health

         information;

 

    5.  Right to receive an accounting of disclosures of your health information as required to be maintained by

         law by delivering a written request to our office using the form we provide to you upon

         request.  An accounting will not include internal uses of information of treatment, payment, or

         operations, disclosures made to you or made at your request, or disclosures made to family members

         or friends in the course of providing care;

 

    6.  Right to confidential communication by requesting that communication of your health information 

         be made by alternative means or at an alternative means or at an alternative location by delivering

         the request in writing to our office using the form we give you upon request: and

 

If you want to exercise any of the above rights, please contact   (Privacy Officer)  (870-935-0861)   (1003 Windover, Jonesboro, AR 72401), in person or in writing, during normal business hours.  She will provide you with assistance on the steps to take to exercise your rights.

 

You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and healthcare operations purposes.     

 

 

 

Our Responsibilities

 

 

 

The office is required to:

 

h   Maintain the privacy of your health information as required by law;

 

h   Provide you with a notice as to our duties and privacy practices as to the information we collect and

       maintain about you;

 

h   Abide by the terms of this Notice;

 

h   Notify you if we cannot accommodate a requested restriction or request; and

 

h   Accommodate your reasonable requests regarding methods to communicate health information with

       you.

 

h   Accommodate your request for an accounting of disclosures.

 

 

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain.  If our information practices change, we amend our Notice.  You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.

 

 

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To Request Information or File a Complaint

 

 

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Privacy Officer at (879) 935-0861.

 

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Privacy Officer.  You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services whose street address and e-mail address is

Office of Inspector General

Department of Health & Human Services

Room 5541, Cohen Building

330 Independence Avenue, S.W.

Washington, D.C. 20201

e-mail address: paffairs@oig.hhs.gov

 

h   We cannot, and will not, require you to waive the right to file a complaint with the Secretary of

       Health and Human Services (HHS) as a condition of receiving treatment from the office.

 

h   We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and

       Human Services.

 

 

Following is a List of Other Uses and Disclosures Allowed by the Privacy Rule

 

Patient Contact

 

We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you.  We may contact you as part of a fund raising effort.

 

Notification - Opportunity to Agree or Object

 

Unless you object we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

 

Communication with Family - Using our best judgment, we may 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 in payment for such care if you do not object or in an emergency.

 

We may use and disclose your protected health information to assist in disaster relief efforts.

 

Opportunity to Agree or Object Not Required

 

PUBLIC HEALTH ACTIVITIES

 

 

Controlling Disease - As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

 

Child Abuse & Neglect - We may disclose protected health information to public authorities as allowed by law to report child abuse or neglect.

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Food and Drug Administration (FDA) - We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

 

 

VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE

We can disclose protected health information to governmental authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment the doctor believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.

 

OVERSIGHT AGENCIES

Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities to include audits, civil, administrative or criminal investigations: inspections; licensures or disciplinary actions, and for similar reasons related to the administration of healthcare.

 

JUDICIAL/ADMINISTRATIVE PROCEEDINGS

We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order or administrative tribunal, provided that only the protected health information released is expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process.

 

LAW ENFORCEMENT

We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, including laws that require reporting of certain types of wounds or other physical injury.

 

CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS

We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

 

ORGAN PROCUREMENT ORGANIZATIONS

Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.

 

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 protected health information.

 

THREAT TO HEALTH AND SAFETY

To avert a serious threat to health and safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

 

FOR SPECIALIZED GOVERNMENTAL FUNCTIONS

We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

 

CORRECTIONAL INSTITUTIONS

If you are an inmate of a correctional institution, we may disclose to the institution or it’s agents the protected health information necessary for your health and the health and safety of other individuals.

 

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WORKERS COMPENSATION

If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

 

Other Uses and Disclosures

h  Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization which you may revoke except to the extent information or action has already been taken.

Website

h  If we maintain a website that provides information about our entity, this Notice will be on the website

 

 

Effective Date:  April 14, 2003