EAST SUBURBAN SPORTS MEDICINE CENTER
2735 MOSSIDE BOULEVARD, SUITE 201
MONROEVILLE, PA 15146
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.
Purpose of Notice
Under the federal health care privacy regulations pertaining
to the Health Insurance Portability and Accountability Act of 1996 set forth
at 45 CFR ¤ 160.101 et seq. (the ÒPrivacy RegulationsÓ), East Suburban Sports
Medicine Center (Òthe PracticeÓ) is required to protect the privacy of your
individually identifiable health information, which includes information about
your health history, symptoms, test results, diagnoses, treatment, and claims
and payment history. We are also required to provide you with this Notice of Protected
Health Information Practices regarding our legal duties, policies and procedures
to protect and maintain the privacy of your health information (Òthe NoticeÓ).
We will not use or disclose your health information except as provided
for in this Notice. However, we reserve the right to change
the terms of this Notice and make new notice provisions for all your health
information that we maintain.
Permitted Uses and Disclosures of Your Health Information
1.
Uses and Disclosures with Patient Consent:
Under the Privacy Regulations, after having made good faith efforts
to obtain your acknowledgement of receipt of this Notice, we are permitted
to use and disclose your health information for the following purposes:
a.
Treatment.
We are permitted to use your health information in the provision and
coordination of your health care. We
may disclose information contained in your medical record to your primary
health care provider, consulting providers, and to other health care personnel
who have a need for such information for your care and treatment. For example, your physical therapist may
disclose your health information when consulting with a physician regarding
your medical condition.
b.
Payment.
We are permitted to use your health information for the purposes of
determining coverage, billing, claims management, medical data processing
and reimbursement. This information
may be released to an insurance company, third party payor or other authorized
entities involved in the payment of your medical bill and may include copies
or portions of your medical record which are necessary for payment of your
account. For example, a bill
sent to your insurance company may include information that identifies you,
your diagnosis, and the procedures and supplies used in your treatment.
c.
Health Care Operations. We are permitted to use and disclose your
health information during the Practice's routine health care operations, including,
but not limited to, quality assurance, utilization reviews, medical reviews,
auditing, accreditation, certification, licensing or credentialing activities
and for education purposes.
2.
Uses and Disclosures With Patient Authorization. Under the Privacy Regulations,
we can
use and disclose your health information for purposes
other than treatment, payment or health care operations with your written
authorization. For example, with
your authorization we can provide your name and medical condition to companies
who might be able to provide you useful items or services. Under the Privacy Regulations, you may
revoke your authorization; however, such revocation will not have any effect
on uses or disclosures of your health information prior to our receipt of
the revocation.
3.
Uses and Disclosures With Patient Opportunity
to Verbally Agree or Object.
Under the Privacy Regulations, we are permitted to disclose your health
information without your written consent or authorization to a family member,
a close personal friend or any other person identified by you, if the information
is directly relevant to that person's involvement in your care or treatment. You must be notified in advance of the
use or disclosure and have the opportunity to verbally agree or object.
4.
Uses and Disclosures Without an Acknowledgement,
Authorization or Opportunity to Verbally Agree or Object. Under the Privacy Regulations, we
are permitted to use or disclose your health information without your consent,
authorization or the opportunity to verbally agree or object with regard to
the following:
a.
Uses and Disclosures Required by Law. We will disclose your health information
when required to do so by law.
b.
Public Health Activities. We may disclose your health information
for public health reporting, reporting of communicable diseases and vital
statistics and similar other circumstances.
c.
Abuse and Neglect.
We may disclose your health information if we have a reasonable belief
of abuse, neglect or domestic violence.
d.
Regulatory Agencies.
We may disclose your health information to a health care oversight
agency for activities authorized by law, including, but not limited to, licensure,
certification, audits, investigations and inspections. These activities are necessary for the
government and certain private health oversight agencies to monitor the health
care system, government programs and compliance with civil rights.
e.
Judicial and Administrative Proceedings. We may disclose health information in
judicial and administrative proceedings, as well as in response to an order
of a court, administrative tribunal, or in response to a subpoena, summons,
warrant, discovery request or similar legal request.
f.
Law Enforcement Purposes. We may disclose your health information
to law enforcement officials when required to do so by law.
g.
Coroners, Medical Examiners, Funeral Directors. We may disclose your health information
to a coroner or medical examiner. This
may be necessary, for example, to determine a cause of death. We may also disclose your health information
to funeral directors, as necessary, to carry out their duties.
h.
Research.
Under certain circumstances, we may disclose your health information
to researchers when their clinical research study has been approved by an
institutional review board that has reviewed the research proposal and provided
that certain safeguards are in place to ensure the privacy and protection
of your health information.
i.
Threats to Health and Safety. We may use or disclose your health
information if we believe, in good faith, the use or disclosure is necessary
to prevent or lessen a serious or imminent threat to the health or safety
of a person or the public.
j.
Military/Veterans.
If you are a member of the armed forces, we may disclose your health
information as required by military command authorities.
k.
WorkersÕ Compensation. We may disclose your health information
to the extent necessary to comply with laws relating to workersÕ compensation
or other similar programs.
l.
Marketing.
We may use or disclose your health information to make a marketing
communication to you, if such communication is conducted face-to-face, concerns
products or services of nominal value, or identifies us as the communicating
party and that we will receive remuneration for making the communication and,
where required by the Privacy Regulations, instructions describing how you
may verbally object to receiving future communications.
m.
Appointment Reminders. We may use and disclose your health information
to remind you of an appointment for treatment and medical care at our practice.
n.
Other Uses and Disclosures. In addition to the reasons outlined above,
we may use and disclose your health information for other purposes permitted
by the Privacy Regulations.
5.
Uses and Disclosures to Business Associates. With an acknowledgement or a proper authorization,
we are permitted to disclose your health information to Business Associates
and to allow Business Associates to receive your health information on our
behalf. A Business Associate
is defined under the Privacy Regulations as an individual or entity under
contract with us to perform or assist us in a function or activity which requires
the use of your health information. Examples of business associates include, but are not limited
to, consultants, accountants, lawyers, medical transcriptionists and third
party billing companies. We require
all Business Associates to protect the confidentiality of your health information.
Patient Rights
Although your medical record is our property, you have
the following rights concerning your medical record and health information:
1.
Right to Request Restrictions on the Use
and Disclosure of Your Health Information.
You have the right to request restrictions on the use and disclosure
of your health information for treatment, payment and health care operations. However, we are not required to agree
with such a request. If, however,
we agree to the requested restriction, it is binding on us.
2.
Right to Inspect and Copy Your Health
Information. You have the right to inspect and copy
your own health information upon request.
However, we are not required to provide you access to all the health
information that we maintain. For
example, this right does not extend to psychotherapy notes, information compiled
in reasonable anticipation of, or for use in, a civil, criminal or administrative
proceeding, or subject to or exempt from Clinical Laboratory Improvements
Amendments of 1988. Access may
also be denied if disclosure would reasonably endanger you or another person.
3.
Right to Verbally Object. You have the right to verbally object to certain disclosures
that are routinely made for treatment, payment or healthcare operations or
for other purposes without an Authorization.
For example, we are required to give you an opportunity to object to
the sharing of your health information with a person or family member accompanying
you for treatment.
4.
Right to Seek an Amendment of Your Health
Information. You have the right to request an amendment
of your health information. If
we disagree with the requested amendment, we will permit you to include a
statement in the record. Moreover,
we will provide you with a written explanation of the reasons for the denial
and the procedures for filing appropriate complaints and appeals.
5.
Right to an Accounting of Disclosure of
Your Health information. You
have the right to receive an accounting of disclosures made by us of your
health information within six (6) years prior to the date of your request;
provided, however that we need not provide an accounting for any information
disclosed prior to April 14, 2003. The
accounting will not include disclosures related to treatment, payment or health
care operations, disclosures made to you, disclosures made pursuant to a validly
executed authorization, disclosures permitted by the Privacy Regulations,
disclosures to persons involved in your care, or disclosures that occurred
prior to the April 14, 2003 compliance deadline under the Privacy Regulations.
The accounting of disclosures shall include the date of each disclosure,
name and address of the person or organization who received your health information,
a brief description of the information disclosed, and the purpose for the
disclosure.
6.
Right to Confidential Communications. You have the right to receive confidential
communications of your health information by alternative means or alternative
locations. For example, you may
request that we only contact you at work or by mail.
7.
Right to Revoke Your Authorization. You have the right to revoke a validly
executed authorization for the use or disclosure of your health information.
However, such revocation will not have any effect on uses or disclosures
prior to the receipt of the revocation.
8.
Right to Receive Copy of this Notice. You have the right to receive a copy of
this Notice.
Contact Information and How to Report a Privacy
Rights Violation
If you have questions and would like additional information
regarding the uses and disclosures of your health information, you may contact
the Compliance Officer, John Bonaroti, P.T., at 412-856-8060x210.
Moreover, the Practice has established an internal complaint process
for reporting privacy rights violations.
If you believe that your privacy rights have been violated, you may
file a complaint with us or the Secretary of the Department of Health and
Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201. To file a complaint with us, please contact the Compliance
Officer, John Bonaroti, P.T., at 412-856-8060x210. All complaints must be submitted to the Practice in writing
at 2735 Mosside Boulevard, Suite 201, Monroeville, PA 15146. There will be no retaliation for filing
a complaint.
Effective Date
The effective date of this Notice is April 14, 2003
EAST SUBURBAN SPORTS MEDICINE CENTER
2735 MOSSIDE BOULEVARD, SUITE 201
MONROEVILLE, PA 15146
Acknowledgement of Receipt of Privacy Notice
Purpose
of this Acknowledgement
This Acknowledgement, which allows the Practice to
use and/or disclosure personally identifiable health information for treatment,
payment or healthcare operations, is made pursuant to the requirements of
45 CFR ¤164.520(c)(2)(ii), part of the federal privacy regulations for the
Health Insurance Privacy and Accountability Act of 1996 (the "Privacy
Regulations").
Please read the following
information carefully:
1.
I understand and acknowledge that I am consenting to the use and/or
disclosure of personally identifiable health information about me by East
Suburban Sports Medicine Center (the "Practice") for the purposes
of treating me, obtaining payment for treatment of me, and as necessary in
order to carry out any healthcare operations that are permitted in the Privacy
Regulations.
2.
I am aware that the Practice maintains a Privacy Notice which sets
forth the types of uses and disclosures that the Practice is permitted to
make under the Privacy Regulations and sets forth in detail the way in which
the Practice will make such use or disclosure.
By signing this Acknowledgement, I understand and acknowledge that
I have received a copy of the Privacy Notice.
3. I understand and
acknowledge that in its Privacy Notice, the Practice has reserved the right
to change its Privacy Notice as it sees fit from time to time. If I wish to obtain a revised Privacy
Notice, I need to send a written request for a revised Privacy Notice to the
office of the Practice at the following address:
2735
Mosside Boulevard, Suite 201, Monroeville, PA 15146, Attention:
Practice Compliance Director.
4. I
understand and acknowledge that I have the right to request that the Practice
restrict how my information is used or disclosed to carry out treatment, payment
or healthcare operations. I understand
and acknowledge that the Practice is not required to agree to restrictions
requested by me, but if the Practice agrees to such a requested restriction
it will be bound by that restriction until I notify it otherwise in writing.
I request the following restrictions be placed on the
Practice's use and/or disclosure of my health information (leave blank if
no restrictions):
I understand the foregoing provisions, and I wish
to sign this Acknowledgement authorizing the use of my personally identifiable
health information for the purposes of treatment, payment for treatment and
healthcare operations.
By
signing this form, I acknowledge that I have reviewed an executed copy of
this acknowledgement and a copy
of
the Practice's Policy Notice and agree to the Practice's use and disclosure
of my protected health information
for
treatment, payment and health care operations.
Signature of Patient or Representative
Date
Patient's Name
Date of Birth
Social Security Number
Name of Personal Representative (if applicable)
Relationship to Patient
To Be Completed by the Practice
The requested restrictions on the use and/or disclosure
of the patientÕs health information set forth above are:
Accepted
Denied
Not Applicable
Other (explain) __________________________________________________________
Signature of Authorized Practice Representative
Date