Notice of Interventional Pain Medicine, P.C. Privacy Practices Effective Date: January 27, 2015 This notice describes how medical information about you may be used and disclosed, as well as how you can obtain access to this information. Please review it carefully.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to ask each of our patients to acknowledge receipt of our Notice of Privacy Practices. The Notice is published on this page. You acknowledge receipt of this notice by accepting terms and conditions for joining Interventional Pain Medicine, P.C. (IPM). IPM. affiliates, together, designate themselves as a single Affiliated Covered Entity (“ACE”) for purposes of compliance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), including without limitation. Each of the sites, locations and care providers will follow the terms of this joint notice. In addition, the entities, sites, locations and care providers may share medical information with each other for treatment, payment, or health care operations related to the ACE. This designation may be amended from time-to-time to add new covered entities that are under common control with IPM. Responsibilities Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Interventional Pain Medicine, P.C. must take steps to protect the privacy of your “Protected Health Information” (PHI). PHI includes information that we have created or received regarding your health or payment for your health. It includes both your medical records and personal information such as your name, social security number, address, and phone number. Under federal law, we are required to: Protect the privacy of your PHI. All of our employees and physicians are required to maintain the confidentiality of PHI and receive appropriate privacy training Provide you with this Notice of Privacy Practices explaining our duties and practices regarding your PHI Follow the practices and procedures set forth in the Notice Uses and Disclosures of Your Protected Health Information That Do Not Require Your Authorization Interventional Pain Medicine, P.C. uses and discloses PHI in a number of ways connected to your treatment, payment for your care, and our health care operations. Some examples of how we may use or disclose your PHI without your authorization are listed below.
To our physicians, nurses, and others involved in your health care or preventive health care. To our different departments to coordinate such activities as prescriptions, lab work, and X-rays. To other health care providers treating you who are not on our staff such as dentists, emergency room staff, and specialists. For example, if you are being treated for an injured knee we may share your PHI among your primary physician, the knee specialist, and your physical therapist so they can provide proper care.
To administer your health benefits policy or contract. To bill you for health care we provide. To pay others who provided care to you. To other organizations and providers for payment activities unless disclosure is prohibited by law.
To administer and support our business activities or those of other health care organizations (as allowed by law) including providers and plans. For example, we may use your PHI to review and improve the care you receive and to provide training. To other individuals (such as consultants and attorneys) and organizations that help us with our business activities. (Note: If we share your PHI with other organizations for this purpose, they must agree to protect your privacy.)
We may use or disclose your Protected Health Information without your authorization for legal and/or governmental purposes in the following circumstances: Required by law – When we are required to do so by state and federal law, including workers’ compensation laws.
Public health and safety – To an authorized public health authority or individual to: Protect public health and safety. Prevent or control disease, injury, or disability. Report vital statistics such as births or deaths. Investigate or track problems with prescription drugs and medical devices. (Food and Drug Administration.)
Abuse or neglect – To government entities authorized to receive reports regarding abuse, neglect, or domestic violence.
Oversight agencies – To health oversight agencies for certain activities such as audits, examinations, investigations, inspections, and licensures.
Legal proceedings – In the course of any legal proceeding in response to an order of a court or administrative agency and, in certain cases, in response to a subpoena, discovery request, or other lawful process.
Law enforcement – To law enforcement officials in limited circumstances for law enforcement purposes. For example disclosures may be made to identify or locate a suspect, witness, or missing person; to report a crime; or to provide information concerning victims of crimes.
Military activity and national security – To the military and to authorized federal officials for national security and intelligence purposes or in connection with providing protective services to the President of the United States. We may also use or disclose your Protected Health Information without your authorization in the following miscellaneous circumstances:
Family and friends—To a member of your family, a relative, a close friend—or any other person you identify who is directly involved in your health care—when you are either not present or unable to make a health care decision for yourself and we determine that disclosure is in your best interest. For example, we may disclose PHI to a friend who brings you into an emergency room. All of this information except religious affiliation will be disclosed to people who ask for you by name. Members of the clergy will be told your religious affiliation if they ask. This is to help your family, friends, and clergy visit you in the facility and generally know how you are doing.
Treatment alternatives and plan description—To communicate with you about treatment services, options, or alternatives, as well as health-related benefits or services that may be of interest to you, or to describe our health plan and providers to you.
De-identify information—If information is removed from your PHI so that you can’t be identified, as authorized by law. Coroners, funeral directors, and organ donation—To coroners, funeral directors, and organ donation organizations as authorized by law.
Disaster relief—To an authorized public or private entity for disaster relief purposes. For example, we might disclose your PHI to help notify family members of your location or general condition.
Threat to health or safety—To avoid a serious threat to the health or safety of yourself and others.
Correctional facilities—If you are an inmate in a correctional facility we may disclose your PHI to the correctional facility for certain purposes, such as providing health care to you or protecting your health and safety or that of others.
Uses and Disclosures of Your Protected Health Information That Require Us to Obtain Your Authorization Except in the situations listed in the sections above, we will use and disclose your PHI only with your written authorization. This means we will not use your Protected Health Information in the following cases, unless you give us written permission: Marketing Purposes Sale of your information most sharing of psychotherapy notes In some situations, federal and state laws provide special protections for specific kinds of PHI and require authorization from you before we can disclose that specially protected PHI. In these situations, we will contact you for the necessary authorization. In some situations, you may revoke your authorization; instructions regarding how to do so are contained in the form authorization you obtain from us. If you have questions about these laws, please contact the Administrative Officer at 718 479 3900.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the right to: Request restrictions by asking that we limit the way we use or disclose your PHI for treatment, payment, or health care operations. You may also ask that we limit the information we give to someone who is involved in your care, such as a family or friend. Please note that we are not required to agree to your request except when a restriction has been requested regarding a disclosure to a health plan in situations where the patient has paid for services in full and where the purpose of the disclosure is for payment or healthcare operations. If we do agree, we will honor your limits unless it is an emergency situation. Ask that we communicate with you by another means. For example, if you want us to communicate with you at a different address we can usually accommodate that request. We may ask that you make your request to us in writing. We will agree to reasonable requests. Request an electronic or paper copy of your PHI. We may ask you to make this request in writing and we may charge a reasonable fee for the cost of producing and mailing the copies, which you will receive usually within 30 days. In certain situations we may deny your request and will tell you why we are denying it. In some cases you may have the right to ask for a review of our denial. Ask usually to amend PHI about you that we use to make decisions about you. Your request for an amendment must be in writing and provide the reason for your request. In certain cases we may deny your request, in writing. You may respond by filing a written statement of disagreement with us and ask that the statement be included with your PHI. Seek an accounting of certain disclosures by asking us for a list of the times we have disclosed your PHI. Your request must be in writing and give us the specific information we need in order to respond to your request. You may request disclosures made up to six years before your request. You may receive one list per year at no charge. If you request another list during the same year, we may charge you a reasonable fee. These lists will not include disclosures to other organizations that might pay for your care provided by Interventional Pain Medicine, P.C.. Request a paper copy of this Notice. Receive written notification of any breach of your unsecured PHI. File a complaint if you believe your privacy rights have been violated. You can file a written complaint with us at the address below, or with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. Email By utilizing our services or replying to our emails, you acknowledge that you are aware that email is not a secure method of communication, and that you agree to the risks. If you would prefer not to exchange personal health information via email, please notify us at firstname.lastname@example.org. Changes to Privacy Practices Interventional Pain Medicine, P.C. may change the terms of this Notice at any time. The revised Notice would apply to all PHI that we maintain. We will make any such changes to our website.
QUESTIONS AND COMPLAINTS
If you have any questions about this Notice or would like an additional copy, please contact the Administrative Officer at 718 479 3900 or email@example.com. If you think that we may have violated your privacy rights or you disagree with a decision we made about access to your PHI, you may send a written complaint to the Administrative Officer at 196-17 Hillside Avenue Hollis, NY 11423.