Page
2 (Notice of Privacy Policies)
Your
Rights With Respect to Your Personal Health Information
Under
HIPAA, you have certain rights with respect to your personal
health information. The following is a brief overview of
your rights and our duties with respect to enforcing those
rights.
Right
To Request Restrictions On Use Or Disclosure
You
have the right to request restrictions on certain uses and
disclosures of your personal health information about
yourself. You may request restrictions on the following uses
or disclosures:
a)
to carry out treatment, payment, or healthcare
operations.
b)
disclosures to family members, relatives, or close personal
friends of personal health information directly relevant to
your care or
payment
related to your health care, or your location, general
condition, or death.
c)
instances in which you are not present or your permission
cannot practicably be obtained due to your incapacity or an
emergency circumstance.
d)
permitting other persons to act on your behalf to pick up
filled prescriptions, medical supplies, X-rays, or other
similar forms of personal
health information.
e)
disclosure to a public or private entity authorized by law
or by its charter to assist in disaster relief
efforts.
While
we are not required to agree to any requested restriction,
if we agree to a restriction, we are bound not to use or
disclose your personal healthcare information in violation
of such restriction, except in certain emergency situations.
We will not accept a request to restrict uses or disclosures
that are otherwise required by law.
Right
To Receive Confidential Communications
You
have the right to receive confidential communications of
your personal health information. We may require written
requests. We may condition the provision of confidential
communications on you providing us with information as to
how payment will be handled and specification of an
alternative address or other method of contact. We may
require that a request contain a statement that disclosure
of all or a part of the information to which the request
pertains could endanger you. We may not require you to
provide an explanation of the basis for your request as a
condition of providing communications to you on a
confidential basis. We must permit you to request and must
accommodate reasonable requests by you to receive
communications of personal health information from us by
alternative means or at alternative locations.
Right
To Inspect And Copy Your Personal Health Information
Your
designated record set is a group of records we maintain that
includes Medical records and billing records about you, or
enrollment, payment, claims adjudication, and case or
medical management records systems, as applicable. You have
the right of access in order to inspect and obtain a copy
your personal health information contained in your
designated record set, except for:
a)
psychotherapy notes, including certain psychological
counseling notes made during routine office visits. .
b)
information compiled in reasonable anticipation of, or for
use in, a civil, criminal, or administrative action or
proceeding.
c)
health information maintained by us to the extent to which
the provision of access to you would be prohibited by
law.
We
will require written requests. We must provide you with
access to your personal health information in the form or
format requested by you, if it is readily producible in such
form or format, or, if not, in a readable hard copy form or
such other form or format.
We
may provide you with a summary of the personal health
information requested, in lieu of providing access to the
personal health information or may provide an explanation of
the personal health information to which access has been
provided, if you agree in advance to such a summary or
explanation and agree to the fees imposed for such summary
or explanation.
We
will provide you with access as requested in a timely
manner, including arranging with you a convenient time and
place to inspect or obtain copies of your personal health
information or mailing a copy to you at your request. We
will discuss the scope, format, and other aspects of your
request for access as necessary to facilitate timely access.
If you request a copy of your personal health information or
agree to a summary or explanation of such information, we
may charge a reasonable cost-based fee for copying, postage,
if you request a mailing, and the costs of preparing an
explanation or summary as agreed upon in advance. We reserve
the right to deny you access to and copies of certain
personal health information as permitted or required by law.
We will reasonably attempt to accommodate any request for
personal health information by, to the extent possible,
giving you access to other personal health information after
excluding the information as to which we have a ground to
deny access. Upon denial of a request for access or request
for information, we will provide you with a written denial
specifying the legal basis for denial, a statement of your
rights, and a description of how you may file a complaint
with us. If we do not maintain the information that is the
subject of your request for access but we know where the
requested information is maintained, we will inform you of
where to direct your request for access.
Right
To Amend Your Personal Health Information
You
have the right to request that we amend your personal health
information or a record about you contained in your
designated record set, for as long as the designated record
set is maintained by us. We have the right to deny your
request for amendment, if:
a)
we determine that the information or record that is the
subject of the request was not created by us, unless you
provide a reasonable
basis to believe that the originator of the information is
no longer available to act on the requested amendment.
b)
the information is not part of your designated record set
maintained by us.
c)
the information is prohibited from inspection by law.
d)
the information is accurate and complete.
We
will require that you submit written requests and provide a
reason to support the requested amendment. If we deny your
request, we will provide you with a written denial stating
the basis of the denial, your right to submit a written
statement disagreeing with the denial, and a description of
how you may file a complaint with us or the Secretary of the
U.S. Department of Health and Human Services ("DHHS"). This
denial will also include a notice that if you do not submit
a statement of disagreement, you may request that we include
your request for amendment and the denial with any future
disclosures of your personal health information that is the
subject of the requested amendment. Copies of all requests,
denials, and statements of disagreement will be included in
your designated record set. If we accept your request for
amendment, we will make reasonable efforts to inform and
provide the amendment within a reasonable time to persons
identified by you as having received personal health
information of yours prior to amendment and persons that we
know have the personal health information that is the
subject of the amendment and that may have relied, or could
foreseeably rely, on such information to your detriment. All
requests for amendment shall be sent to:
William
H. McMicken, M.D
Internal Medicine Associates, Inc.
2600 Philmont Avenue, Suite 323
Huntingdon Valley, PA 19006
Right
To Receive An Accounting Of Disclosures Of Your Personal
Health Information
Beginning
April 14, 2003, you have the right to receive a written
accounting of all disclosures of your personal health
information that we have made within the six (6) year period
immediately preceding the date on which the accounting is
requested. You may request an accounting of disclosures for
a period of time less than six (6) years from the date of
the request. Such disclosures will include the date of each
disclosure, the name and, if known, the address of the
entity or person who received the information, a brief
description of the information disclosed, and a brief
statement of the purpose and basis of the disclosure or, in
lieu of such statement, a copy of your written authorization
or written request for disclosure pertaining to such
information. We are not required to provide accountings
of disclosures for the following purposes:
a)
treatment, payment, and healthcare operations.
b)
disclosures pursuant to your authorization.
c)
disclosures to
d)
for a facility directory or to persons involved in your
care.
e)
for national security or intelligence purposes.
f)
to correctional institutions.
g)
with respect to disclosures occurring prior to
4/14/03.
Continued
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