NOTICE OF PRIVACY
PRACTICES
LITTLE FLOWER
FAMILY PRACTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT
YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Effective Date: 8/20/2013
Updated: 2/28/2021
IF YOU HAVE ANY
QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR
PRIVACY OFFICER:
Privacy Officer: Donna
Johns
Mailing Address: 211
15th St NW Canton, OH 44703
Telephone: (330) 455-0800
Fax: (330)
455-1453
About This Notice
We are required by
law to maintain the privacy of Protected Health Information and to give you
this Notice explaining our privacy practices with regard to that information.
You have certain rights – and we have certain legal obligations – regarding the
privacy of your Protected Health Information, and this Notice also explains
your rights and our obligations. We are required to abide by the terms of the
current version of this Notice.
What is Protected Health Information?
“Protected Health
Information” is information that individually identifies you and that we create
or get from you or from another health care provider, health plan, your
employer, or a health care clearinghouse and that relates to (1) your past,
present, or future physical or mental health or conditions, (2) the provision
of health care to you, or (3) the past, present, or future payment for your
health care.
How We May Use and Disclose Your Protected
Health Information
We may use and
disclose your Protected Health Information in the following circumstances:
- For Treatment. We may use or disclose your Protected
Health Information to give you medical treatment or services and to manage and
coordinate your medical care. For example, your Protected Health Information
may be provided to a physician or other health care provider (e.g., a
specialist or laboratory) to whom you have been referred to ensure that the
physician or other health care provider has the necessary information to
diagnose or treat you or provide you with a service.
- For Payment. We may use and disclose your Protected
Health Information so that we can bill for the treatment and services you
receive from us and can collect payment from you, a health plan, or a third
party. This use and disclosure may include certain activities that your health
insurance plan may undertake before it approves or pays for the health care
services we recommend for you, such as making a determination of eligibility or
coverage for insurance benefits, reviewing services provided to you for medical
necessity, and undertaking utilization review activities. For example, we may need to give your health
plan information about your treatment in order for your health plan to agree to
pay for that treatment.
- For Health Care Operations. We may use and
disclose Protected Health Information for our health care operations. For
example, we may use your Protected Health Information to internally review the
quality of the treatment and services you receive and to evaluate the
performance of our team members in caring for you. We also may disclose information
to physicians, nurses, medical technicians, medical students, and other
authorized personnel for educational and learning purposes.
- Appointment Reminders/Treatment
Alternatives/Health-Related Benefits and Services. We may use and
disclose Protected Health Information to contact you to remind you that you
have an appointment for medical care, or to contact you to tell you about
possible treatment options or alternatives or health related benefits and
services that may be of interest to you.
- Minors. We may disclose the Protected Health
Information of minor children to their parents or guardians unless such
disclosure is otherwise prohibited by law.
- As Required by Law. We will disclose Protected Health
Information about you when required to do so by international, federal, state,
or local law.
- To Avert a Serious Threat to Health or Safety. We may use and
disclose Protected Health Information when necessary to prevent a serious
threat to your health or safety or to the health or safety of others. But we
will only disclose the information to someone who may be able to help prevent
the threat.
- Business Associates. We may disclose Protected Health
Information to our business associates who perform functions on our behalf or
provide us with services if the Protected Health Information is necessary for
those functions or services. For example, we may use another company to do our
billing, or to provide transcription or consulting services for us. All of our business associates are obligated,
under contract with us, to protect the privacy and ensure the security of your
Protected Health Information.
- Organ and Tissue Donation. If you are an
organ or tissue donor, we may use or disclose your Protected Health Information
to organizations that handle organ procurement or transplantation – such as an
organ donation bank – as necessary to facilitate organ or tissue donation and
transplantation.
- Military and Veterans. If you are a
member of the armed forces, we may disclose Protected Health Information as
required by military command authorities. We also may disclose Protected Health
Information to the appropriate foreign military authority if you are a member
of a foreign military.
- Workers’ Compensation. We may use or
disclose Protected Health Information for workers’ compensation or similar
programs that provide benefits for work-related injuries or illness.
- Public Health Risks. We may disclose
Protected Health Information for public health activities. This includes
disclosures to: (1) a person subject to the jurisdiction of the Food and Drug
Administration (“FDA”) for purposes related to the quality, safety or
effectiveness of an FDA-regulated product or activity; (2) prevent or control
disease, injury or disability; (3) report births and deaths; (4) report child
abuse or neglect; (5) report reactions to medications or problems with
products; (6) notify people of recalls of products they may be using; and (7) a
person who may have been exposed to a disease or may be at risk for contracting
or spreading a disease or condition.
- Abuse, Neglect, or Domestic Violence. We may disclose Protected Health Information
to the appropriate government authority if we believe a patient has been the
victim of abuse, neglect, or domestic violence and the patient agrees or we are
required or authorized by law to make that disclosure.
- Health Oversight Activities. We may disclose
Protected Health Information to a health oversight agency for activities
authorized by law. These oversight activities include, for example, audits,
investigations, inspections, licensure, and similar activities that are
necessary for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
- Data Breach Notification Purposes. We may use or
disclose your Protected Health Information to provide legally required notices
of unauthorized access to or disclosure of your health information.
- Lawsuits and Disputes. If you are
involved in a lawsuit or a dispute, we may disclose Protected Health
Information in response to a court or administrative order. We also may
disclose Protected Health Information in response to a subpoena, discovery
request, or other legal process from someone else involved in the dispute, but
only if efforts have been made to tell you about the request or to get an order
protecting the information requested. We may also use or disclose your
Protected Health Information to defend ourselves in the event of a lawsuit.
- Law Enforcement. We may disclose Protected Health
Information, so long as applicable legal requirements are met, for law
enforcement purposes.
- Military Activity and National Security. If you are
involved with military, national security or intelligence activities or if you
are in law enforcement custody, we may disclose your Protected Health
Information to authorized officials so they may carry out their legal duties
under the law.
- Coroners, Medical Examiners, and Funeral Directors. We may disclose
Protected Health Information to a coroner, medical examiner, or funeral
director so that they can carry out their duties.
- Inmates. If you are an inmate of a correctional
institution or under the custody of a law enforcement official, we may disclose
Protected Health Information to the correctional institution or law enforcement
official if the disclosure is necessary (1) for the institution to provide you
with health care; (2) to protect your health and safety or the health and
safety of others; or (3) the safety and security of the correctional
institution.
- Individuals Involved in Your Care or Payment for Your
Care.
Unless you object, we may disclose to a member of your family, a relative, a
close friend or any other person you identify, your Protected Health
Information that directly relates to that person’s involvement in your health
care. If you are unable to agree or
object to such a disclosure, we may disclose such information as necessary if
we determine that it is in your best interest based on our professional
judgment.
- Disaster Relief. We may disclose your Protected
Health Information to disaster relief organizations that seek your Protected
Health Information to coordinate your care, or notify family and friends of
your location or condition in a disaster. We will provide you with an
opportunity to agree or object to such a disclosure whenever we practicably can
do so.
- Federal laws
restrict disclosure of psychotherapy notes, but these should not be confused
with mental health records that are part of the patient’s health record, such
as progress notes. Mental health records can be released.
- If we receive drug
and alcohol records from a specialized drug and alcohol program, unit or staff
that is federally assisted, we may not re-disclose the information without
express written consent from you. Questions we ask and information collected
here is not part of that restriction and can be shared.
- Right to Inspect and Copy. You have the
right to inspect and copy Protected Health Information that may be used to make
decisions about your care or payment for your care. We have up to 30 days to
make your Protected Health Information available to you and we may charge you a
reasonable fee for the costs of copying, mailing or other supplies associated
with your request. We may not charge you a fee if you need the information for
a claim for benefits under the Social Security Act or any other state or federal
needs-based benefit program. We may deny your request in certain limited
circumstances. If we do deny your request, you have the right to have the
denial reviewed by a licensed healthcare professional who was not directly
involved in the denial of your request, and we will comply with the outcome of
the review.
- Right to a Summary or Explanation. We can also provide you with a summary of your Protected Health
Information, rather than the entire record, or we can provide you with an
explanation of the Protected Health Information which has been provided to you,
so long as you agrees to this alternative form and pay the associated fees.
- Right to Get Notice of a Breach. You have the
right to be notified upon a breach of any of your unsecured Protected Health
Information.
- Right to Request Amendments. If you feel that
the Protected Health Information we have is incorrect or incomplete, you may
ask us to amend the information. You have the right to request an amendment for
as long as the information is kept by or for us. A request for amendment must
be made in writing to the Privacy Officer at the address provided at the
beginning of this Notice and it must tell us the reason for your request. In
certain cases, we may deny your request for an amendment. If we deny your request
for an amendment, you have the right to file a statement of disagreement with
us and we may prepare a rebuttal to your statement and will provide you with a
copy of any such rebuttal.
- Right to an Accounting of Disclosures. You have the
right to ask for an “accounting of disclosures,” which is a list of the
disclosures we made of your Protected Health Information. This right applies to
disclosures for purposes other than treatment, payment or healthcare operations
as described in this Notice. It excludes disclosures we may have made to you,
for a resident directory, to family members or friends involved in your care,
or for notification purposes. The right to receive this information is subject
to certain exceptions, restrictions and limitations. Additionally, limitations
are different for electronic health records. The first accounting of
disclosures you request within any 12-month period will be free. For additional
requests within the same period, we may charge you for the reasonable costs of
providing the accounting. We will tell what the costs are, and you may choose
to withdraw or modify your request before the costs are incurred.
- Right to Request Restrictions. You have the
right to request a restriction or limitation on the Protected Health Information
we use or disclose for treatment, payment, or health care operations. You also
have the right to request a limit on the Protected Health Information we
disclose about you to someone who is involved in your care or the payment for
your care, like a family member or friend. To request a restriction on who may
have access to your Protected Health Information, you must submit a written
request to the Privacy Officer. Your request must state the specific
restriction requested and to whom you want the restriction to apply. We are not required to agree to your request,
unless you are asking us to restrict the use and disclosure of your Protected
Health Information to a health plan for payment or health care operation
purposes and such information you wish to restrict pertains solely to a health
care item or service for which you have paid us “out-of-pocket” in full. If we
do agree to the requested restriction, we may not use or disclose your
Protected Health Information in violation of that restriction unless it is
needed to provide emergency treatment.
- Out-of-Pocket-Payments. If you paid
out-of-pocket (or in other words, you have requested that we not bill your
health plan) in full for a specific item or service, you have the right to ask
that your Protected Health Information with respect to that item or service not
be disclosed to a health plan for purposes of payment or health care
operations, and we will honor that request.
- Right to Request Confidential Communications. You have the
right to request that we communicate with you only in certain ways to preserve
your privacy. For example, you may request that we contact you by mail at a
specific address or call you only at your work number. You must make any such
request in writing and you must specify how or where we are to contact you. We
will accommodate all reasonable requests. We will not ask you the reason for
your request.
- Right to a Paper Copy of This Notice. You have the
right to a paper copy of this Notice, even if you have agreed to receive this
Notice electronically. You may request a copy of this Notice at any time.
Uses and Disclosures That Require Us to
Give You an Opportunity to Object and Opt Out
- Sharing
in Community Health Record. We
may share information in a community health record through CliniSync, that
allows other physicians and facilities that are caring for your health to
have access to the information they need to care for you appropriately. If
you object to this sharing you can contact CliniSync directly and obtain
an opt-out form from their website:
www.clinisync.org/member-resoures/policies-documents and choose Request To Change Consent
Form.
Your Written Authorization is Required for
Other Uses and Disclosures
The following uses
and disclosures of your Protected Health Information will be made only with
your written authorization:
1. Most uses and disclosures of
psychotherapy notes;
2. Uses and disclosures of
Protected Health Information for marketing purposes; and
3. Disclosures that constitute a sale of
your Protected Health Information.
Other uses and
disclosures of Protected Health Information not covered by this Notice or the
laws that apply to us will be made only with your written authorization. If you
do give us an authorization, you may revoke it at any time by submitting a
written revocation to our Privacy Officer and we will no longer disclose
Protected Health Information under the authorization. But disclosure that we
made in reliance on your authorization before you revoked it will not be
affected by the revocation.
Your Rights Regarding Your Protected Health Information
You have the
following rights, subject to certain limitations, regarding your Protected
Health Information:
Right
to an Electronic Copy of Electronic Medical Records. If your Protected Health
Information is maintained in an electronic format (known as an electronic
medical record or an electronic health record), you have the right to request
that an electronic copy of your record be given to you or transmitted to
another individual or entity. We will make every effort to provide access to your Protected
Health Information in the form or format you request,
if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you
request your record will be provided in either our standard electronic format
or if you do not want this form or format, a readable
hard copy form. We may charge
you a reasonable, cost-based fee for the labor associated with transmitting the
electronic medical record.
How to Exercise Your Rights
To exercise your
rights described in this Notice, send your request, in writing, to our Privacy
Officer at the address listed at the beginning of this Notice. We may ask you
to fill out a form that we will supply. To exercise your right to inspect and
copy your Protected Health Information, you may also contact your physician
directly. To get a paper copy of this Notice, contact our Privacy Officer by
phone or mail.
Changes To This Notice
We reserve the
right to change this Notice. We reserve the right to make the changed Notice
effective for Protected Health Information we already have as well as for any
Protected Health Information we create or receive in the future. A copy of our
current Notice is posted in our office and on our website.
Complaints
You may file a
complaint with us or with the Secretary of the United States Department of
Health and Human Services if you believe your privacy rights have been
violated.
To file a
complaint with us, contact our Privacy Officer at the address listed at the beginning
of this Notice. All complaints must be made in writing and should be submitted
within 180 days of when you knew or should have known of the suspected
violation. There will be no retaliation against you for filing a complaint.
To file a
complaint with the Secretary, mail it to: Secretary of the U.S. Department of
Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201.
Call (202) 619-0257 (or toll free (877) 696-6775) or go to the website of the
Office for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. There
will be no retaliation against you for filing a complaint.