NOTICE OF HEALTH INFORMATION 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.
Alpine Family Practice P.C. is required to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices. Alpine Family Practice P.C. will not use or disclose your health information except as described in this Notice. This Notice applies to all of the medical records generated by the Alpine Family Practice P.C. as well as records we receive from other providers.
USES AND DISCLOSURES REQUIRING YOUR CONSENT: With your consent, Alpine Family Practice P.C. may use and disclose your health information for the following purposes.
TREATMENT: Alpine Family Practice P.C. may use your health information in the provision and coordination of your healthcare. We may disclose all or any portion of your medical record information to your attending physician, consulting physician(s), nurses, technicians, medical students, and other health care providers who have a legitimate need for such information in your care and treatment. Different departments may share health information about you in order to coordinate specific services, such as prescriptions, lab work and x-rays. Alpine Family Practice P.C. also may disclose your health information to people outside Alpine Family Practice P.C. who may be involved in your medical care after you leave Alpine Family Practice P.C. , such as family members, clergy and others used to provide services that are part of your care. Other ways we may use or disclose your health information for purposes related to treatment are:
" Treatment Alternatives: To tell you about or recommend possible treatment options or alternatives that may be of interest to you.
" Appointment Reminders: To contact you as a reminder that you have an appointment for treatment or medical care at Alpine Family Practice P.C. .
PAYMENT: Alpine Family Practice P.C. may release health information about you for the purposes of determining coverage, billing, claims management, medical data processing, and reimbursement. The information may be released to an insurance company, third party payer or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record which are necessary for payment of your account. For example, a bill sent to a third party payer may include information that identifies you, your diagnosis, and the procedures and supplies used. We may also provide payment information to other care providers who have been involved in your care, e.g., an ambulance company.
ROUTINE HEALTHCARE OPERATIONS: Alpine Family Practice P.C. may use and disclose your health information during routine healthcare operations, including quality assurance, utilization review, medical review, internal auditing, accreditation, certification, licensing or credentialing activities of Alpine Family Practice P.C. , medical research and educational purposes. Alpine Family Practice P.C. may engage outside companies to carry out certain aspects of routine healthcare operations. These entities are called the "business associates" of Alpine Family Practice P.C. . Alpine Family Practice P.C. may need to disclose your health information to the business associates to allow them to perform their duties. The business associates will, in turn, use and disclose your health information as they conduct business on Alpine Family Practice P.C. behalf. Examples of business associates, include, but are not limited to, a copy service used by Alpine Family Practice P.C. to copy medical records, consultants, accountants, lawyers, medical transcriptionists and third-party billing companies. Alpine Family Practice P.C. requires the business associate to protect the confidentiality of your health information.
USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION: Alpine Family Practice P.C. may not disclose your health information to persons outside of Alpine Family Practice P.C. for purposes other than treatment, payment or healthcare operations without your authorization. In addition, Alpine Family Practice P.C. may not use or disclose psychotherapy notes written by your mental health provider, if any, without your authorization, even for treatment, payment or healthcare operations. You have the right to revoke any authorization you have previously given by submitting a written statement of revocation toAlpine Family Practice P.C. .
USES AND DISCLOSURES TO WHICH YOU MAY OBJECT:
FAMILY/FRIENDS: Alpine Family Practice P.C. may disclose your health information to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. [We may also tell your family or friends of your condition and that you are in the Hospital.] In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you have any objection to the use and disclosure of your health information in this manner, please tell us.
USES AND DISCLOSURES THAT ARE REQUIRED OR PERMITTED WITHOUT CONSENT OR AUTHORIZATION
RESEARCH: Under certain circumstances, Alpine Family Practice P.C. may use and disclose your health information to approved clinical research studies. While most clinical research studies require specific patient consent, there are some instances where a retrospective record review with no patient contact may be conducted by such researchers. For example, the research project may involve comparing the health and recovery of patients who received one medication for their medical condition to those who received a different medication for that same condition.
REGULATORY AGENCIES: Alpine Family Practice P.C. may disclose your health information to government and certain private health oversight agencies, e.g., the Department of Public Health and Environment, the Joint Commission on Accreditation of Healthcare Organizations or the Board of Medical Examiners, for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations and inspections. These activities are necessary to monitor compliance with the requirements of government programs.
LAW ENFORCEMENT/LITIGATION: Alpine Family Practice P.C. may disclose your health information for law enforcement purposes as required by law or in response to a court order.
PUBLIC HEALTH: As required by law, the Alpine Family Practice P.C. may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, Alpine Family Practice P.C. is required to report the existence of a communicable disease, such as acquired immune deficiency syndrome ("AIDS"), to the Department of Public Health and Environment to protect the health and well-being of the general public.
WORKERS' COMPENSATION: Alpine Family Practice P.C. may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
MILITARY/VETERANS: Alpine Family Practice P.C. may disclose your health information as required by military command authorities, if you are a member of the armed forces.
AS OTHERWISE REQUIRED BY LAW: Alpine Family Practice P.C. will disclose your health information in any situation in which such disclosure is required by law (e.g., child abuse, domestic abuse).
YOUR RIGHTS RELATED TO YOUR HEALTH INFORMATION: Although all records concerning your treatment obtained at Alpine Family Practice P.C. are the property of Alpine Family Practice P.C. , you have the following rights concerning your health information:
RIGHT TO CONFIDENTIAL COMMUNICATIONS: You have the right to receive confidential communications of your health information by alternative means or at alternative locations. For example, you may request that Alpine Family Practice P.C. only contact you at work or by mail.
RIGHT TO INSPECT AND COPY: You generally have the right to inspect and copy your health information, except as restricted by your physician or by law.
RIGHT TO AMEND: You have the right to request an amendment or correction to your health information. If we agree that an amendment or correction is appropriate, we will ensure that the amendment or correction is attached to your medical record.
RIGHT TO AN ACCOUNTING: You have the right to obtain a statement of the disclosures that have been made of your health information other than by your authorization, other than to you and other than for the purpose of treatment, payment or routine operational purposes.
RIGHT TO REQUEST RESTRICTIONS: You have the right to request restrictions on certain uses and disclosures of your health information. If we are able to agree to your request, we will abide by the restrictions.
RIGHT TO RECEIVE COPY OF THIS NOTICE: You have the right to receive a paper copy of this Notice, upon request, if this Notice has been provided to you electronically.
RIGHT TO REVOKE CONSENT OR AUTHORIZATION: You have the right to revoke your consent or authorization to use or disclose your health information, except to the extent that action has already been taken in reliance on your consent or authorization.
FOR MORE INFORMATION REGARDING HOW TO EXERCISE THESE RIGHTS: If you have questions or would like more information regarding any of the rights listed above, please contact: Alpine Family Practice P.C. at (303) 752-1157.
IF YOU BELIEVE THAT YOUR RIGHTS HAVE BEEN VIOLATED: You may file a complaint with Alpine Family Practice P.C. or with the Secretary of the Department of Health and Human Services. To file a complaint with Alpine Family Practice P.C. , please contact:Alpine Family Practice P.C. at (303)752-1157. All complaints must be submitted in writing. There will be no retaliation for filing a complaint.
CHANGES TO THIS NOTICE: Alpine Family Practice P.C. will abide by the terms of the Notice currently in effect. Alpine Family Practice P.C. reserves the right to change the terms of this Notice at any time. Any new notice provisions will be effective for all protected health information that it maintains. Alpine Family Practice P.C. will mail any revised Notice to the address indicated on the General Admission Agreement, Patient Information Forms or such other address you may provide to us from time to time.
NOTICE EFFECTIVE DATE: The effective date of the Notice is August 18, 2003.