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 Effective Date: April 14, 2003 NOTICE OF PRIVACY PRACTICES 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 PT Northwest’s Privacy Officer Kennedy
I. Hawkins at 503.540.8701. Mr. Hawkins works out of PT Northwest’s
administrative office. The address is 685 36th Ave. NE Salem, OR
97301 This
notice describes the procedures and practices that this clinic and its
professional, support and administrative staff follow to protect the privacy of
your health information. YOUR
HEALTH INFORMATION This
notice applies to the information and records we have about your health, health
status, and the health care and services you receive at this office. Your health information may include
information created and received by this office, it may be in the form of
written or electronic records or spoken words, and it may include information
about your health history, health status, symptoms, examinations, test results,
diagnoses, treatments, procedures, prescriptions, related billing activity and
similar types of health-related information. We
are required by law to give you this notice.
It will tell you about the ways in which we may use and disclose health
information about you and describes your rights and our obligations regarding
the use and disclosure of that information. HOW
WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU We
may use and disclose health information for the following purposes:
For example, the doctor who referred you for
physical therapy may be treating you for a medical or orthopedic condition and
we may need to know about that and any other health problems that could
complicate your treatment. We may use
your medical history to decide what treatment is best for you. We will consult with your doctor and send
reports about your treatment to the doctor.
We do this to provide the most appropriate care for you. Different personnel in our office may share
information about you and disclose information to people who do not work in our
office in order to coordinate your care, such as telephoning your doctor and
getting needed information. Family
members and other health care providers may be part of your physical therapy
outside this office and that may require us to provide information about you. ·
For Payment. We
may need to disclose health information about you in order to bill your health
plan or insurance company or other third party for your treatment in this
clinic. We
may also need to tell your health plan or insurance company about a treatment
you are going to receive in order to obtain prior approval, or to determine
whether your plan will pay for the treatment. ·
For Health Care Operations. We may use and disclose health information about you in order to
manage the clinic and ensure that you and our other patients receive quality
care. For example, we may use your health information to
evaluate the performance of our staff in caring for you. We may also use health information about all
or many of our patients to help us decide what additional services we should
offer, how we can become more efficient, or whether certain treatments are
effective for certain problems. We may also disclose your health information to
your health plan and other health care providers that care for you in order to
help these plans and providers evaluate or improve care, reduce cost,
coordinate and manage health care and services, train staff and comply with the
law. ·
Appointment Reminders. We may contact you to remind you of your appointment. ·
Treatment Alternatives. We may tell you about or recommend possible treatment options or
alternatives that may interest you. ·
Health-Related Products and Services. We may tell you about health-related products or services that
may interest you. Please notify us if you do not wish to be contacted
for appointment reminders, or if you do not wish to receive communications
about treatment alternatives or health-related products and services. If you advise us in writing (at the
address listed at the top of this Notice) that you do not wish to receive these
communications, we will not use or disclose your information for these
purposes. OTHER CIRCUMSTANCES We may use or disclose health information about you for the
following purposes, in accordance with the requirements and limitations of
state and other law: ·
To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when
necessary to prevent a serious threat to your health and safety or the health
and safety of the public or another person. ·
Required By Law. We will disclose
health information about you when required to do so by federal, state or local
law. ·
Research. We may use
and disclose health information about you for research projects that are
subject to a special approval process.
We will ask you for your permission if the researcher will have access
to your name, address or other information that reveals who you are, or will be
involved in your care at the office. ·
Military, Veterans, National Security and Intelligence. If you are or were a member of the armed forces, or part of the
national security or intelligence communities, we may be required by military
command or other government authorities to release health information about
you. We may also release information
about foreign military personnel to the appropriate foreign military authority. ·
Workers’ Compensation. We may release health information about you for workers’
compensation or similar programs. These
programs provide benefits for work-related injuries or illness. ·
Public Health Risks. We may disclose
health information about you for public health reasons in order to prevent or
control disease, injury or disability; or report suspected abuse or neglect,
non-accidental physical injuries or problems with products. ·
Health Oversight Activities. We may disclose health information to a health oversight agency
for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for
certain state and federal agencies to monitor the health care system,
government programs, and compliance with civil rights laws. ·
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose
health information about you in response to a court or administrative
order. Subject to all applicable legal
requirements, we may also disclose health information about you in response to
a subpoena. ·
Law Enforcement. We may release
health information if asked to do so by a law enforcement official in response
to a court order, subpoena, warrant, summons or similar process, subject to all
applicable legal requirements. ·
Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical
examiner. This may be necessary, for
example, to identify a deceased person or determine the cause of death. ·
Information Not Personally Identifiable. We may use or disclose health information about you in a way that
does not personally identify you or reveal who you are. ·
Family and Friends. We may
disclose health information about you to your family members or friends if we
obtain your verbal agreement to do so or if we give you an opportunity to
object to such a disclosure and you do not raise an objection. We may also disclose health information to
your family or friends if we can infer from the circumstances, based on our
professional judgment that you would not object. For example, we may assume you agree to our disclosure of your
personal health information to your spouse when you bring your spouse with you
into the room during treatment or while treatment is discussed. In
situations where you are not capable of giving consent (due to your incapacity
or medical emergency), we may, using our professional judgment, determine that
a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only
health information relevant to the person’s involvement in your care. OTHER USES AND DISCLOSURES PURSUANT TO YOUR SIGNED
AUTHORIZATION We will not use
or disclose your health information for any purpose other than those identified
in the previous sections without your specific, written Authorization. If you sign an Authorization for us
to use or disclose health information about you, you may revoke that Authorization,
in writing, at any time. If you
revoke your Authorization, we will no longer use or disclose information
about you for the reasons covered by your written Authorization, but we
cannot take back any uses or disclosures already made with your permission. YOUR RIGHTS
REGARDING YOUR HEALTH INFORMATION You have the
following rights regarding health information we maintain about you: ·
Right to Inspect and Copy. You have the right to inspect and copy your
health information, such as medical and billing records, that we keep and use
to make decisions about your care. You
must submit a written request to Kennedy I. Hawkins PT Northwest’s Privacy
Officer in order to inspect and/or copy records of your health
information. If you request a copy of
the information, we may charge a fee for the costs of copying, mailing or other
associated supplies. We may deny your request to inspect and/or copy
records in certain limited circumstances.
If you are denied copies of or access to, health information that we
keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our
denial reviewed, we will select a licensed health care professional to review
your request and our denial. The person
conducting the review will not be the person who denied your request, and we
will comply with the outcome of the review. ·
Right to Correct. If you believe health
information we have about you is incorrect or incomplete, you may ask us to
amend the information. You have the
right to request a correction as long as the information is kept by this
office. To
request a correction, complete and submit a MEDICAL RECORD AMENDMENT/CORRECTION
FORM to Kennedy I. Hawkins PT Northwest’s
Privacy Officer. We will provide you with one of these forms at your request. We
may deny your request for an amendment if your request is not in writing
or does not include a reason to support the request. In addition, we may deny your request if you ask us to correct
information that: ·
We did not create, unless the person or entity that created the
information is no longer available to make the correction ·
Is not part of the health information that we keep ·
You would not be permitted to inspect and copy ·
Is accurate and complete ·
Right to an Accounting of Disclosures. You have the right to request an “accounting of
disclosures.” This is a record of the
disclosures we made of medical information about you for purposes other than
treatment, payment, health care operations, and a limited number of special
circumstances involving national security, correctional institutions and law
enforcement. The record may also
exclude any disclosures we have made based on your written authorization. To
obtain this accounting, you must submit your request in writing to Kennedy
I. Hawkins PT Northwest’s Privacy Officer. The request must state the time period
for which you want an accounting. The
time period may not be longer than six years and may not include dates before
April 14, 2003. Your request should
indicate in what form you want the list (for example, on paper,
electronically). The first list you
request within a 12-month period will be free.
For additional lists, we may charge you for the costs of providing the
list. We will notify you of the cost
involved and you may choose to withdraw or modify your request at that time
before any costs are incurred. ·
Right to Request Restrictions. You have the right to request a restriction or limitation on the health
information we use or disclose about you for treatment, payment or health care
operations. You also have the right to request a limit on the health
information we disclose about you to someone who is involved in your care or
the payment for it, like a family member or friend. For example, you could ask that we not use or disclose
information about a surgery you had. We
are not required to agree to your request. If we do agree, we will comply with your request unless the information
is needed to provide you emergency treatment or we are required by law to use
or disclose the information. To
request restrictions, you may complete and submit the REQUEST FOR RESTRICTION
ON USE/DISCLOSURE OF MEDICAL INFORMATION AND/OR CONFIDENTIAL COMMUNICATION to Kennedy
I. Hawkins PT Northwest’s Privacy Officer. We will
provide you with one of these forms at your request. ·
Right to Request Confidential Communications. You have the right to request that we communicate with you about
medical matters in a certain way or at a certain location. For example, you can ask that we only
contact you at work or by mail or e-mail. To request confidential communications, you may
complete and submit the REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF MEDICAL
INFORMATION AND/OR CONFIDENTIAL COMMUNICATION to Kennedy I. Hawkins PT Northwest’s Privacy Officer. We will not ask you the reason for your
request. We will accommodate all
reasonable requests. Your request must
specify how or where you wish to be contacted. ·
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this
notice at any time. Even if you have
agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact Kennedy I. Hawkins PT Northwest’s Privacy Officer. CHANGES
TO THIS NOTICE We reserve the right to change this notice, and to make the
revised or changed notice effective for medical information we already have
about you as well as any information we receive in the future. We will post the current notice or a summary of the current notice in
the office with its effective date in the top right hand corner. You are entitled to a copy of the notice
currently in effect. COMPLAINTS If
you believe your privacy rights have been violated, you may file a complaint
with our office or with the Secretary of the Department of Health and Human
Services. To file a complaint with our
office, contact Kennedy I. Hawkins President & General Manager PT
Northwest, LLC 685 36th Ave. NE Salem, OR 97301. His phone number is
503.540.8701. You will not be penalized for filing a complaint. |
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