Summary of
NOTICE OF PRIVACY PRACTICES
For MD ORTHOTIC & PROSTHETIC LABS, PC.
This summary briefly describes important information
contained in our Notice of Privacy Practices. We encourage you to take
the time to read the complete Notice, which is attached to this summary.
Our Notice of Privacy Practices describes how we may use and disclose your
protected health information to carry out treatment, payment or health care
operations and for other purposes that are permitted or required by law. It
also describes your rights to access and control your protected health
information. Your "protected health information" means any of your written and
oral health information, including your demographic data that can be used to
identify you. This is health information that is created or received by your
health care provider, and that relates to your past, present or future physical
or mental health or condition.
This Notice will let you know about the various ways we use and disclose your
medical information, describe your rights and our obligations with respect to the
use or disclosure of your medical information. We will also ask that you
acknowledge receipt of this Notice the first time you come to or use any of our
facilities, because the law requires us to make a good faith effort to obtain your
acknowledgment.
We are required by law to:
Make sure that any medical or health information that we have that identifies
you is kept private, and will be used or disclosed only in accord with our Notice
of Privacy Practices and applicable law;
Give you the complete Notice of our legal duties and our privacy practices; and
Abide by the terms of the Notice of Privacy Practices that is in effect
from time to time.
NOTICE OF PRIVACY PRACTICES
For MD ORTHOTIC & PROSTHETIC LABS, PC.
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 have any questions about this Notice please contact:
Jonathan Devens at 312-337-0811 x124
OUR COMMITMENT TO PROTECT YOUR HEALTH INFORMATION
This Notice of Privacy Practices describes how we may use and disclose your
protected health information to carry out treatment, payment or health care
operations and for other purposes that are permitted or required by law. It also
describes your rights to access and control your protected health information.
Your "protected health information" means any of your written and oral health
information, including your demographic data that can be used to identify you.
This is health information that is created or received by your health care provider,
and that relates to your past, present or future physical or mental health or
condition.
We are strongly committed to protecting your medical information. We create a
medical record about your care because we need the record to provide you with
appropriate treatment and to comply with various legal requirements. We transmit
some medical information about your care in order to obtain payment for the
services you receive, and we use certain information in our day to day operations.
This Notice will let you know about the various ways we use and disclose your
medical information, describe your rights and our obligations with respect to
the use or disclosure of your medical information. We will also ask that you
acknowledge receipt of this Notice the first time you come to or use any of
our facilities, because the law requires us to make a good faith effort to
obtain your acknowledgment.
We are required by law to:
Make sure that any medical or health information that we have that identifies
you is kept private, and will be used or disclosed only in accord with this
Notice of Privacy Practices and applicable law;
Give you this Notice of our legal duties and our privacy practices; and
Abide by the terms of the Notice of Privacy Practices that is in effect from
time to time.
1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
A. Uses and Disclosures of Protected Health Information for Treatment,
Payment and Healthcare Operations
Your protected health information may be used and disclosed by your
(Orthotist or Prosthetist), our office staff and others outside of our office
who are involved in your care and treatment for the purpose of providing
health care services to you. Your protected health information may also
be used and disclosed to pay your health care bills and to support the
operation of this MD Orthotic & Prosthetic Labs, PC.
Following are examples of the types of uses and disclosures of your protected
health care information that this MD Orthotic & Prosthetic Labs, PC. is permitted to
make. We have provided some examples of the types of each use or disclosure we may
make, but not every use or disclosure in any of the following categories will be
listed.
For Treatment: We will use and disclose your
protected health information to provide, coordinate, or manage your health
care and any related treatment. This includes the coordination or management
of your health care with a third party that has already obtained your
permission to have access to your protected health information. For example,
we would disclose your protected health information, as necessary, to
the physician that referred you to us. We will also disclose protected
health information to other health care providers who may be treating
you when we have the necessary permission from you to disclose your protected
health information.
For Payment: Your protected health information
will be used, as needed, to obtain payment for your health care services.
This 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. We may also tell your health
plan about an orthotic or prosthetic device you are going to receive to
obtain prior approval or to determine whether your plan will cover the
device.
For Healthcare Operations: We may use or disclose,
as needed, your protected health information in order to support the business
activities of this MD Orthotic & Prosthetic Labs, PC. These activities
include, but are not limited to, quality assessment activities, employee
review activities, legal services, licensing, and conducting or arranging
for other business activities. We may share your protected health information
with third party "business associates" that perform various activities
(e.g., billing, transcription services) for this MD Orthotic & Prosthetic
Labs, PC. Whenever an arrangement between our MD Orthotic & Prosthetic
Labs, PC and our business associate involves the use or disclosure of
your protected health information, we will have a written contract that
contains terms that will protect the privacy of your protected health
information.
Treatment Alternatives: We may use or disclose
your protected health information, as necessary, to provide you with information
about treatment alternatives or other health-related benefits and services
that may be of interest to you.
Appointment Reminders: We may use or disclose
your protected health information, as necessary, to contact you to remind
you of your appointment.
Sign In Sheets: We may use a sign-in sheet at
the registration desk where you will be asked to sign your name. We may
also call you by name in the waiting room when your (Orthotist or Prosthetist)
is ready to see you.
Marketing and Health Related Benefits and Services:
We may also use and disclose your protected health information for other
marketing activities. For example, we may send you information about products
or services that we believe may be beneficial to you. You may contact
our Privacy Contact to request that these materials not be sent to you.
Sale of the Practice: If we decide to sell this
practice or merge or combine with another practice, we may share your
protected health information with the new owners.
B. Uses and Disclosures of Protected Health Information Based
upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only
with your written authorization, unless otherwise permitted or required by law as
described below. You may revoke your authorization, at any time, in writing. You
understand that we can not take back any use or disclosure we may have made under the
authorization before we received your written revocation, and that we are required to
maintain a record of the medical care that has been provided to you. The
authorization is a separate document, and you will have the opportunity to review any
authorization before you sign it. We will not condition your treatment in any way on
whether or not you sign any authorization.
C. Other Permitted and Required Uses and Disclosures That May
Be Made Either With Your Agreement or the Opportunity to Object
We may use and disclose your protected health information in the following
instances. You have the opportunity to agree or object to the use or disclosure of
all or part of your protected health information. If you are not present or able to
agree or object to the use or disclosure of the protected health information, then
your (Orthotist or Prosthetist) may, using their professional judgment, determine
whether the disclosure is in your best interest. In this case, only the protected
health information that is relevant to your health care will be disclosed.
Others Involved in Your Healthcare: Unless you
object, we may disclose to a member of your family, a relative, a close
friend or any other person you identify, orally or in writing, 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. We may use
or disclose your protected health information to notify or assist in notifying
a family member, personal representative or any other person that is responsible
for your care of your location or general condition.
D. Other Permitted and Required Uses and Disclosures That May
Be Made Without Your Authorization or Opportunity to Object
We may use or disclose your protected health information in the following
situations without your authorization or providing you the opportunity
to object.
Required By Law: We may use or disclose your
protected health information to the extent that the use or disclosure
is required by federal, state or local law. The use or disclosure will
be made in compliance with the law and will be limited to the relevant
requirements of the law. You will be notified, as required by law, of
any such uses or disclosures.
Public Health: We may disclose your protected
health information for public health activities and purposes to a public
health authority that is permitted by law to collect or receive the information.
The disclosure will be made for the purpose of controlling disease, injury
or disability. A disclosure under this exception would only be made to
somebody in a position to help prevent the threat to public health
Communicable Diseases: We may disclose your protected
health information, if authorized by law, to a person who may have been
exposed to a communicable disease or may otherwise be at risk of contracting
or spreading the disease or condition.
Health Oversight: We may disclose protected health
information to a health oversight agency for activities authorized by
law, such as audits, investigations, and inspections. Oversight agencies
seeking this information include government agencies that oversee the
health care system, government benefit programs, other government regulatory
programs and civil rights laws.
Abuse or Neglect: We may disclose your protected
health information to a public health authority that is authorized by
law to receive reports of child abuse or neglect. In addition, we may
disclose your protected health information if we believe that you have
been a victim of abuse, neglect or domestic violence to the governmental
entity or agency authorized to receive such information. We will only
make this disclosure if you agree or when required or authorized by law.
In this case, the disclosure will be made consistent with the requirements
of applicable federal and state laws.
Military and Veterans: If you are a member of
the military, we may release protected health information about you as
required by military command authorities.
Food and Drug Administration: We may disclose
your protected health information to a person or company required by the
Food and Drug Administration to report adverse events, product defects
or problems, biologic product deviations, track products; to enable product
recalls; to make repairs or replacements, or to conduct post marketing
surveillance, as required.
Legal Proceedings: We may disclose your protected
health information in the course of any judicial or administrative proceeding,
in response to an order of a court or administrative tribunal (to the
extent such disclosure is expressly authorized), in certain conditions
in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose your protected
health information, so long as applicable legal requirements are met,
for law enforcement purposes. These law enforcement purposes might include
(1) legal processes and otherwise required by law, (2) limited information
requests for identification and location purposes, (3) pertaining to victims
of a crime, (4) suspicion that death has occurred as a result of criminal
conduct, (5) in the event that a crime occurs on the premises of the practice,
and (6) medical emergency (not on the MD Orthotic & Prosthetic Labs, PC
premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation:
We may disclose your protected health information to a coroner or medical
examiner for identification purposes, determining cause of death or for
the coroner or medical examiner to perform other duties authorized by
law. We may also disclose protected health information to a funeral director,
as authorized by law, in order to permit the funeral director to carry
out their duties. We may disclose such information in reasonable anticipation
of death. Protected health information may be used and disclosed for cadaveric
organ, eye or tissue donation purposes.
Research: Under certain circumstances, we may
disclose your protected health 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.
Criminal Activity: Consistent with applicable
federal and state laws, we may disclose your protected health information,
if we believe that the use or disclosure is necessary to prevent or lessen
a serious and imminent threat to the health or safety of a person or the
public. We may also disclose protected health information if it is necessary
for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When
the appropriate conditions apply, we may use or disclose protected health
information of individuals who are Armed Forces personnel (1) for activities
deemed necessary by appropriate military command authorities; (2) for
the purpose of a determination by the Department of Veterans Affairs of
your eligibility for benefits, or (3) to foreign military authority if
you are a member of that foreign military services. We may also disclose
your protected health information to authorized federal officials for
conducting national security and intelligence activities, including for
the provision of protective services to the President or others legally
authorized.
Workers' Compensation: We may disclose your protected
health information as authorized to comply with workers' compensation
laws and other similar legally-established programs that provide benefits
for work-related illnesses and injuries.
Inmates: We may use or disclose your protected
health information if you are an inmate of a correctional MD Orthotic
& Prosthetic Labs, Inc. and your (Orthotist or Prosthetist) created or
received your protected health information in the course of providing
care to you.
Required Uses and Disclosures: Under the law,
we must make disclosures to you and when required by the Secretary of
the Department of Health and Human Services to investigate or determine
our compliance with the requirements of the final rule on Standards for
Privacy of Individually Identifiable Health Information.
2. YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
Following is a statement of your rights with respect to your protected health
information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health
information. This means you may inspect and obtain a copy
of your protected health information contained in your medical and billing
records and any other records that your (Orthotist or Prosthetist) uses
for making decisions about you, for as long as we maintain the protected
health information.
To inspect and copy your medical information, you must submit a written request
to the Privacy Contact listed on the first and last pages of this Notice. If you
request a copy of your information, we may charge you a fee for the costs of copying,
mailing or other costs incurred by us in complying with your request.
We may deny your request in limited situations specified in the law. For example,
you may not inspect or copy psychotherapy notes; or information compiled in reasonable
anticipation of, or use in, a civil, criminal, or administrative action or proceeding,
and certain other specified protected health information defined by law. In some
circumstances, you may have a right to have this decision reviewed. The person
conducting the review will not be the person who initially denied your request.
We will comply with the decision in any review. Please contact our Privacy Contact
if you have questions about access to your medical record.
You have the right to request a restriction of your protected
health information. This means you may ask us not to use
or disclose any part of your protected health information for the purposes
of treatment, payment or healthcare operations. You may also request that
any part of your protected health information not be disclosed to family
members or friends who may be involved in your care or for notification
purposes as described in this Notice of Privacy Practices. Your request
must state the specific restriction requested and to whom you want the
restriction to apply.
Your (Orthotist or Prosthetist) is not required to agree
to a restriction that you may request.
If the (Orthotist
or Prosthetist) believes it is in your best interest to permit
use and disclosure of your protected health information, your protected
health information will not be restricted. If your (Orthotist
or Prosthetist) does 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. With
this in mind, please discuss any restriction you wish to request with
your (Orthotist or Prosthetist). You may request a
restriction by [describe how patient may obtain a restriction
— ex. Submit request in writing, contacting Privacy Contact, etc.]
You have the right to request to receive confidential communications
from us by alternative means or at an alternative location.
We will accommodate reasonable requests. We may also condition this accommodation
by asking you for information as to how payment will be handled or specification
of an alternative address or other method of contact. We will not request
an explanation from you as to the basis for the request. Please make this
request in writing to our Privacy Contact.
You may have the right to have your (Orthotist or Prosthetist)
amend your protected health information. This means you may
request an amendment of your protected health information contained in
your medical and billing records and any other records that your
(Orthotist
or Prosthetist) uses for making decisions about you, for as long
as we maintain the protected health information. You must make your request
for amendment in writing to our Privacy Contact, and provide the reason
or reasons that support your request.
We may deny any request that is not in writing or does not state a reason
supporting the request. We may deny your request for an amendment of any
information that:
- Was not created by us, unless the person that created the information is no longer available to amend the information;
- Is not part of the protected health information kept by or for us;
- Is not part of the information you would be permitted to inspect or copy; or
- Is accurate and complete.
If we deny your request for amendment, we will do so in writing and explain the
basis for the denial. You have the right to file a written statement of disagreement
with us. We may prepare a rebuttal to your statement and will provide you with a
copy of any such rebuttal. Please contact our Privacy Contact to determine if you
have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures
we have made, if any, of your protected health information.
This right only applies to disclosures for purposes other than treatment,
payment or healthcare operations as described in this Notice of Privacy
Practices. It also excludes disclosures we may have made to you, to family
members or friends involved in your care, or for notification purposes.
You have the right to receive specific information regarding these disclosures
that occurred after April 14, 2003. The right to receive this information
is subject to certain exceptions, restrictions and limitations. You must
submit a written request for disclosures in writing to the Privacy Contact.
You must specify a time period, which may not be longer than six years
and cannot include any date before April 14, 2003. You may request a shorter
timeframe. Your request should indicate the form in which you want the
list (i.e., on paper, etc). You have the right to one free request within
any 12 month period, but we may charge you for any additional requests
in the same 12 month period. We will notify you about the charges you
will be required to pay, and you are free to withdraw or modify your request
in writing before any charges are incurred.
You have the right to obtain a paper copy of this notice from
us, upon request to our Privacy Contact, or in person at
our office, at any time, even if you have agreed to accept this notice
electronically. [You may obtain a copy of this notice at our website,
www.mdopl.com
3. COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you
believe your privacy rights have been violated by us. You may file a complaint with us
by notifying our privacy contact of your complaint. We will not retaliate against you
in any way for filing a complaint, either with us or with the Secretary.
You may contact our Privacy Contact, Jonathan Devens
at (312)337-0811 x124 or jdevens@mdoandp.com
for further information about the complaint process.
4. CHANGES TO THIS NOTICE
We reserve the right to change the privacy practices that are described in this
Notice of Privacy Practices. We also reserve the right to apply these changes
retroactively to Protected Health Information received before the change in privacy
practices. You may obtain a revised Notice of Privacy Practices by calling the office
and requesting a revised copy be sent in the mail, asking for one at the time of your
next appointment, or accessing our website
This notice was published and becomes effective on
April 14, 2003
FORMS (Click on one of the printable
forms below. A new browser window will pop-up when one of the links is
clicked. Please download the free Adobe
Reader to view the forms below if you do not have Adobe Reader installed.)
Written Acknowledgement of
Receipt of Notice of Privacy Practices
Requesting Restrictions
on Use/Disclosure of PHI
Requesting
Confidential Communications
Requesting Access to PHI
Patient Complaint Form
Patient Authorization