Bel-Park Anesthesia Associates, Inc.
Notice of Privacy
Practices
Effective Date:
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.
We are required by law to protect the privacy of health
information that may reveal your identity, and to provide you with a copy of
this notice which describes the health information privacy practices of our
Anesthesia and Pain Practice and any affiliated health care providers that
jointly perform payment activities and business operations with our practice. A
copy of our current notice will always be posted in the reception area of our
offices. You will also be able to obtain your own copies by accessing our
website at www.belpark.net, calling our office at 330-742-2100, or asking for
one at the time of your next visit.
If you have any questions about this notice or would like further
information, please contact the Privacy Officer at 330-742-2100.
IMPORTANT SUMMARY INFORMATION
Requirement for
Acknowledgment of Notice of Privacy Practices. We will ask you to sign a form that will serve as an
acknowledgment that you have received this Notice of Privacy Practices.
Requirement For Written Authorization. We will generally obtain your written authorization before using
your health information or sharing it with others outside our group practice.
You may also initiate the transfer of your records to another person by
completing an authorization form. If you provide us with written authorization,
you may revoke that authorization at any time, except to the extent that we
have already relied upon it. To revoke an authorization, please contact us
at 330-742-2100.
Exceptions To Requirement. There are some situations when we do not need your written
authorization before using your health information or sharing it with others.
They are:
How To Access Your Health Information. You generally have the right to inspect and copy your
health information. Details about this right are provided below.
How To Correct Your Health Information. You have the right to request that we amend your health
information if you believe it is inaccurate or incomplete. A description of
this right is included below.
How To Keep Track
Of The Ways Your Health Information Has Been Shared With Others. You have the right to receive a list from us, called an
"accounting list," which provides information about when and how we
have disclosed your health information to outside persons or organizations. The
list will identify non-routine disclosures of your information, but routine
disclosures will not be included. The list will not include disclosures you
have authorized. For more information about your right to see this list, see
below.
How To Request Additional Privacy Protections. You have the right to request further restrictions on the
way we use your health information or share it with others. We are not required
to agree to the restriction you request, but if we do, we will be bound by our
agreement.
How To Request More Confidential Communications. You have the right to request that we contact you in a way
that is more confidential for you, such as at home instead of at work. We will
try to accommodate all reasonable requests.
How Someone May
Act On Your Behalf. You have the right to
name a personal representative who may act on your behalf to control the
privacy of your health information. Parents and guardians will generally have
the right to control the privacy of health information about minors unless the
minors are permitted by law to act on their own behalf.
How To Learn About Special Protections For HIV, Substance Abuse,
and Mental Health Information. Special
privacy protections apply to HIV-related information, substance abuse
information, and mental health information. Some parts of this general Notice
of Privacy Practices may not apply to these types of information. If your
treatment involves this information, you will be provided with separate notices
explaining how the information will be protected. To request copies of these
other notices now, please contact our Privacy Officer at 330-742-2100.
How To Obtain A Copy Of This Notice. You have the right to a paper copy of this notice. You may
request a paper copy at any time, even if you have previously agreed to receive
this notice electronically. To do so, please call the Privacy Officer at 330-742-2100.
You may also obtain a copy of this notice from our website at www.belpark.net,
or by requesting a copy at your next visit.
How To Obtain A Copy Of Revised Notices. We may change our privacy practices from time to time. If
we do, we will revise this notice so you will have an accurate summary of our
practices. The revised notice will apply to all of your health information, and
we will be required by law to abide by its terms. We will post any revised
notice in our reception area. You will also be able to obtain your own copy of
the revised notice by accessing our website at www.belpark.net, calling our
office at 330-742-2100, or asking for one at the time of your next visit. The
effective date of the notice will always be located in the top right corner of
the first page.
How To File A Complaint. If
you believe your privacy rights have been violated, you may file a complaint
with us or with the Secretary of the Department of Health and Human Services.
To file a complaint with us, please contact the HIPAA Privacy Officer,
WHAT HEALTH INFORMATION IS PROTECTED
We are committed to protecting the privacy
of information we gather about you while providing health-related services.
Some examples of protected health information are:
HOW WE MAY USE
AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION
1. Treatment,
Payment, And
The physicians and
other clinicians and staff members within our Practice may use your health
information or share it with others in order to treat your condition, obtain
payment for that treatment, and run the practice's normal business operations.
Your health information may also be shared with affiliated hospitals and health
care providers so that they may jointly perform certain payment activities and
business operations along with our practice. Below are further examples of how
your information may be used for treatment, payment, and health care
operations.
Treatment. We may share your health information with doctors or
nurses within our practice who are involved in taking care of you, and they may
in turn use that information to diagnose or treat you. A doctor within our
practice may share your health information with another doctor within our
practice, or with a doctor at another health care institution (such as a
hospital), to determine how to diagnose or treat you. A doctor in our practice
may also share your health information with another doctor to whom you have
been referred for further health care.
Payment. We may use your health information or share it with others
so that we obtain payment for your health care services. For example, we may
share information about you with your health insurance company in order to
obtain reimbursement after we have treated you. We may also share information
about you with your health insurance company to determine whether it will cover
your treatment or to obtain necessary pre-approval before providing you with
treatment.
Business
Operations. We may use your health
information or share it with others in order to conduct our normal business
operations. For example, we may use your health information to evaluate the
performance of our physicians or staff in caring for you, or to educate our
physicians or staff on how to improve the care they provide for you. We may
also share your health information with another company that performs business
services for us, such as billing companies. If so, we will have a written
contract to ensure that this company also protects the privacy of your health
information.
Appointment
Reminders, Treatment Alternatives, Benefits And
Services. We may use your health
information when we contact you with a reminder that you have an appointment
for treatment or services at our facility. We may also use your health information
in order to recommend possible treatment alternatives or health-related
benefits and services that may be of interest to you.
2. Friends And Family
We may use your health information in
our patient directory, or share it with friends and family involved in your
care, without your written authorization. We will always give you an
opportunity to object unless there is insufficient time because of a medical
emergency (in which case we will discuss your preferences with you as soon as
the emergency is over). We will follow your wishes unless we are required by
law to do otherwise.
Friends And
Family Involved In Your Care. If you do not object, we may share your
health information with a family member, relative, or close personal friend who
is involved in your care or payment for that care. We may also notify a family
member, personal representative, or another person responsible for your care
about your general condition or about the unfortunate event of your death. In
some cases, we may need to share your information with a disaster relief
organization that will help us notify these persons.
3. Emergencies Or Public Need.
We may use your health information, and
share it with others, in order to treat you in an emergency or to meet
important public needs. We will not be required to obtain your written
authorization, consent or any other type of permission before using or
disclosing your information for these reasons.
Emergencies.
We may use or disclose your health information if you need emergency treatment
or if we are required by law to treat you but are unable to obtain your
consent. If this happens, we will try to obtain your consent as soon as we
reasonably can after we treat you.
Communication
Barriers. We may use and disclose your health information if we are
unable to obtain your consent because of substantial communication barriers,
and we believe you would want us to treat you if we could communicate with you.
As Required By Law. We may use or disclose your health information if we
are required by law to do so. We also will notify you of these uses and
disclosures if notice is required by law.
Public Health
Activities. We may disclose your health information to authorized
public health officials (or a foreign government agency collaborating with such
officials) so they may carry out their public health activities. For example,
we may share your health information with government officials that are
responsible for controlling disease, injury, or disability. We may also
disclose your health information to a person who may have been exposed to a
communicable disease or be at risk for contracting or spreading the disease if
a law permits us to do so. And finally, we may release some health information
about you to your employer if your employer hires us to provide you with a
physical exam and we discover that you have a work-related injury or disease
that your employer must know about in order to comply with employment laws.
Victims Of
Abuse, Neglect, Or Domestic Violence. We may release your health
information to a public health authority that is authorized to receive reports
of abuse, neglect, or domestic violence. We will make every effort to obtain
your permission before releasing this information, but in some cases we may be
required or authorized to act without your permission.
Health Oversight
Activities. We may release your health information to government
agencies authorized to conduct audits, investigations, and inspections of our
facility. These government agencies monitor the operation of the health care
system, government benefit programs, such as Medicare and Medicaid, and
compliance with government regulatory programs and civil rights laws.
Product Monitoring, Repair And Recall. We may disclose your health information to a
person or company that is required by the Food and Drug Administration to: (1)
report or track product defects or problems; (2) repair, replace, or recall
defective or dangerous products; or (3) monitor the performance of a product
after it has been approved for use by the general public.
Lawsuits And
Disputes. We may disclose your health information if we are ordered to do
so by a court that is handling a lawsuit or other dispute. We may also disclose
your information in response to a subpoena, discovery request, or other lawful
request by someone else involved in the dispute, but only if efforts have been
made to tell you about the request or to obtain a court order protecting the
information from further disclosure.
Law Enforcement.
We may disclose your health information to law enforcement officials for the
following reasons:
To
Avert A Serious Threat To Health Or Safety. We may use your health information or share it with others
when necessary to prevent a serious threat to your health or safety, or the
health or safety of another person or the public. In such cases, we will only
share your information with someone able to help prevent the threat. We may
also disclose your health information to law enforcement officers if you tell
us that you participated in a violent crime that may have caused serious
physical harm to another person (unless you admitted that fact while in
counseling), or if we determine that you escaped from lawful custody (such as a
prison or mental health institution).
National Security And
Intelligence Activities Or Protective Services. We may disclose your health
information to authorized federal officials who are conducting national
security and intelligence activities or providing protective services to the
President or other important officials.
Military And
Veterans. If you are in the Armed Forces, we may disclose health information
about you to appropriate military command authorities for activities they deem
necessary to carry out their military mission. We may also release health
information about foreign military personnel to the appropriate foreign
military authority.
Inmates And
Correctional Institutions. If you are an inmate or you are detained by a
law enforcement officer, we may disclose your health information to the prison
officers or law enforcement officers if necessary to provide you with health
care, or to maintain safety, security, and good order at the place where you
are confined. This includes sharing information that is necessary to protect
the health and safety of other inmates or persons involved in supervising or
transporting inmates or detainees.
Workers' Compensation.
We may disclose your health information for workers' compensation or similar
programs that provide benefits for work-related injuries.
Coroners, Medical Examiners And Funeral Directors. In the unfortunate event of your
death, we may disclose your health information to a coroner or medical
examiner. This may be necessary, for example, to determine the cause of death.
We may also release this information to funeral directors as necessary to carry
out their duties
Organ And
Tissue Donation. In the unfortunate event of your death, we may disclose
your health information to organizations that procure or store organs, eyes, or
other tissues so that these organizations may investigate whether donation or
transplantation is possible under applicable laws.
Research. In most cases, we will ask for your
written authorization before using your health information or sharing it with
others in order to conduct research. However, under some circumstances, we may
use and disclose your health information without your authorization if we
obtain approval through a special process to ensure that research without your
authorization poses minimal risk to your privacy. Under no circumstances,
however, would we allow researchers to use your name or identity publicly. We
may also release your health information without your authorization to people
who are preparing a future research project, so long as any information
identifying you does not leave our offices. In the unfortunate event of your
death, we may share your health information with people who are conducting
research using the information of deceased persons, as long as they agree not
to remove from our offices any information that identifies you.
YOUR RIGHTS TO ACCESS AND CONTROL YOUR
HEALTH INFORMATION
We want you to know that you have the following rights to access and control
your health information. These rights are important because they will help you
make sure that the health information we have about you is accurate. They may
also help you control the way we use your information and share it with others,
or the way we communicate with you about your medical matters.
1. Right To Inspect And Copy Records
You have the right to inspect and obtain a copy of any of your health
information that may be used to make decisions about you and your treatment for
as long as we maintain this information in our records. This includes medical
and billing records. To inspect or obtain a copy of your health information,
please submit your request in writing to [insert name of responsible person or
department]. If you request a copy of the information, we may charge a fee for
the costs of copying, mailing, or other supplies we use to fulfill your
request.
We ordinarily will respond to your request within 30 days if the information is
located in our facility, and within 60 days if it is
located off-site at another facility. If we need additional time to respond, we
will notify you in writing within the time frame above to explain the reason
for the delay and when you can expect to have a final answer to your request.
Under certain very limited circumstances, we may deny your request to inspect
or obtain a copy of your information. If we deny part or all
of your request, we will provide a written denial that explains our reasons
for doing so, and a complete description of your rights to have that decision
reviewed and how you can exercise those rights. We will also include
information on how to file a complaint about these issues with us or with the
Secretary of the Department of Health and Human Services. If we have reason to
deny only part of your request, we will provide complete access to the
remaining parts after excluding the information we cannot let you inspect or
copy.
2. Right To Amend Records
If you believe that the health information we have about you 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 in our records. To
request an amendment, please write to [insert name of responsible person or
department]. Your request should include the reasons why you think we should
make the amendment. Ordinarily we will respond to your request within 60 days.
If we need additional time to respond, we will notify you in writing within 60
days to explain the reason for the delay and when you can expect to have a
final answer to your request.
If we deny part or all of your request, we will
provide a written notice that explains our reasons for doing so. You will have
the right to have certain information related to your requested amendment
included in your records. For example, if you disagree with our decision, you
will have an opportunity to submit a statement explaining your disagreement
which we will include in your records. We will also include information on how
to file a complaint with us or with the Secretary of the Department of Health
and Human Services. These procedures will be explained in more detail in any
written denial notice we send you.
3. Right To An Accounting Of Disclosures
After
To
request this list, please write to [insert name of responsible person or
department]. Your request must state a time period for the disclosures you want
us to include. For example, you may request a list of the disclosures that we
made between
Ordinarily we will respond to your request for an accounting list within 60
days. If we need additional time to prepare the accounting list you have
requested, we will notify you in writing about the reason for the delay and the
date when you can expect to receive the accounting list. In rare cases, we may
have to delay providing you with the accounting list without notifying you
because a law enforcement official or government agency has asked us to do so.
4. Right To Request Additional Privacy
Protections
You have the right to request that we further restrict the way we use and
disclose your health information to treat your condition, collect payment for
that treatment, or run our normal business operations. You may also request
that we limit how we disclose information about you to family or friends
involved in your care. For example, you could request that we not disclose
information about a surgery or therapy you had. To request restrictions, please
write to [insert name of responsible person or department]. Your request should
include (1) what information you want to limit; (2) whether you want to limit
how we use the information, how we share it with others, or both; and (3) to
whom you want the limits to apply.
We are not required to agree to your
request for a restriction, and in some cases the restriction you request may
not be permitted under law. However, if
we do agree, we will be bound by our agreement unless the information is needed
to provide you with emergency treatment or comply with the law. Once we
have agreed to a restriction, you have the right to revoke the restriction at
any time. Under some circumstances, we will also have the right to revoke the
restriction as long as we notify you before doing so; in other cases, we will
need your permission before we can revoke the restriction.
5. Right To Request Confidential Communications
You have the right to request that
we communicate with you about your medical matters in a more confidential way.
For example, you may ask that we contact you at home instead of at work. To
request more confidential communications, please write to [insert name of
responsible person or department]. We
will not ask you the reason for your request, and we will try to accommodate
all reasonable requests. Please specify in your request how or where you
wish to be contacted, and how payment for your health care will be handled if
we communicate with you through this alternative method or location.
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Source: American Society of Clinical Oncologists, 2003 http://www.acso.org/ http://www.asco.org/ Reprinted with permission. |