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.

 

 

I.  What This Is

 

This Notice describes the privacy practices of our Practice.

 

II.  Our Privacy Obligations

 

We are required by law to maintain the privacy of medical and health information about you ("Protected Health Information" or "PHI") and to provide you with this Notice of our legal duties and privacy practices with respect to PHI.  When we use or disclose PHI, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

 

III.  Permissible Uses and Disclosures Without Your Written Consent or Authorization

 

In certain situations, which we will describe in Sections IV and V below, we must obtain your written consent or authorization in order to use and/or disclose your PHI.  However, we do not need any type of consent or authorization from you for the following uses and disclosures:

 

A. Use For Treatment, Payment and Health Care Operations.  We may use (but not disclose to a third party) your PHI in order to treat you, obtain payment for services provided to you and conduct our "health care operations" as detailed below:

 

• Treatment.  We use PHI to provide treatment and other services to you--for example, to diagnose and treat your injury or illness.   In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

 

• Payment.  We may use PHI to obtain payment for services that we provide to you--for example, to identify our claims for payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care ("Your Payor").

 

• Health Care Operations.  We may use PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care and customer service that we deliver to you.  For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers, and we may provide PHI to our office manager in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.

 

B. Disclosure to Relatives, Close Friends and Other Caregivers.   We may disclose PHI, other than Highly Confidential Inforn1ation (described below in Section IV.B), to a family member, other relative, a close personal friend, or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, and do not object to such disclosure after being given the opportunity to do so.  We may also disclose your PHI to such person with your verbal agreement or written consent.

 

If you are incapacitated or in an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend in such circumstances, we would disclose only information that is directly relevant to the person's involvement with your health care or payment related to your health care. We may also disclose PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.

 

C. Public Health Activities. We may disclose PHI for the following public health activities:

 

 (1) to  report  health  information  to  public  health  authorities  for  the  purpose  of  preventing  or controlling disease, injury or disability;

 

(2) to report child abuse and neglect, elder abuse, disabled persons abuse, or rape or sexual assault to public health authorities or other government authorities authorized by law to receive such reports;

 

(3)  to  report  information  about  products  and  services  under  the  jurisdiction  of  the  U.S.  Food and Drug

Administration;

 

(4) if we know or have reason to believe that you are infected with a venereal disease, to alert: (a) your fiancée, if you are engaged, or your spouse, if you are married, or (b) your parent or guardian if you are a minor, unless as a minor you have sought treatment with us for such venereal disease;

 

(5)  to report  information  to  your  insurer  and/or the  Massachusetts  Industrial  Accident  Board  as required under laws addressing work-related illnesses and injuries or workplace medical surveillance;

 

(6) to report information related to the birth and subsequent health of an infant to state government agencies as required by law;

 

(7) to file a death certificate and report fetal deaths; and

 

(8) to report abortions performed after 24 weeks of pregnancy to state government agencies as required by law.

 

 

D. Health Oversight Activities.   We may disclose PHI to a health oversight agency that oversees the health care system or government benefit programs (such as Medicare or Medicaid).

 

E. Judicial and Administrative Proceedings.   We may disclose PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

 

 

F. Law Enforcement   Officials.    We  may  disclose  PHI  to  the  police  or  other  law  enforcement  officials as required or permitted by law or in compliance  with a court order or a grand jury or administrative  subpoena  accompanied by a court order.

 

G. Decedents.   We may disclose PHI to a coroner or medical examiner as authorized by law.

 

H. Organ and Tissue Procurement.   If you are an organ donor, we may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

 

I. Research.   We may use or disclose PHI without your consent or authorization for research purposes if an

Institutional Review Board/Privacy Board approves a waiver of authorization for such use or disclosure.

 

J. Health or Safety.  We may use or disclose PHI to prevent or lessen a serious and imminent danger to you or to others if the disclosure is to a person who is reasonably able to lessen or prevent the threat, including the target of the threat.

 

K. Specialized Government Functions.   We may use and disclose PHI to units of the government  with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances required by law.

 

L. Ordered Examinations.   We may disclose PHI when required to report findings from an examination ordered by a court or detention facility.

 

M.  As required by law.  We may use and disclose PHI when required to do so by any other law not already referred to in the preceding categories.

 

 N. Business Associates.  We may contract with outside businesses to provide some services for us. For example, we may use the services of information technology firms or electronic health record service providers. Under such contracts, we may share your medical information with them to do the job we have asked them to do. These contracts require businesses to protect the medical information we share with them.

 

IV.  Disclosures Requiring Your Written Consent

 

A. Disclosures For Treatment, Payment and Health Care Operations.    With your written consent, we may disclose PHI in order to treat you, obtain payment for services provided to you and conduct our health care operations as detailed below:

 

• Treatment.   We may disclose PHI to provide treatment and other services to you--for example, we may disclose

PHI to other providers involved in your treatment.

 

• Payment.  We may disclose PHI to obtain payment for services that we provide to you--for example, disclosures to file claims and obtain payment from your Payor, or to verify that your Payor will pay for health care.

 

• Health Care Operations.   We may disclose PHI for our health care operations.  For example, we may disclose PHI

in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.

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NOTICE OF PRIVACY PRACTICES

We may also disclose PHI to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.

 

B. Disclosures   of Your Highly Confidential   Information.   Federal  and  state  law  require   special  privacy protections  for  certain  highly  confidential  information  about  you  ("Highly  Confidential  Information"),   including:  (I)  your HIVIAIDS  status; (2) genetic testing  information; (3) confidential  communications  with a psychotherapist,  psychologist, social worker, sexual assault counselor, domestic violence counselor, or other allied mental health professional or human services professional; (4) substance abuse (alcohol or drug) treatment or rehabilitation  information; (5) venereal disease information; (6) abortion  consent form(s); (7)  mammography  records; (8) family  planning  services; (9) treatment  or diagnosis  of emancipated minors; (10) mental health community  program records; and (11) research involving controlled  substances.   In order for us to disclose your Highly Confidential  Information  for a purpose  related to treatment, payment, or health care operations,  we must obtain your separate, specific written consent unless we are otherwise permitted by law to make such disclosure.

 

In addition, if you are an emancipated minor, certain information relating to your treatment or diagnosis may be considered "Highly Confidential Information" and as a result will not be disclosed to your parent or guardian without your consent.   Your consent is not required, however, if a physician reasonably believes your condition to be so serious that your life or limb is endangered.  Under such circumstances, we may notify your parents or legal guardian of the condition, and will inform you of any such notification.

 

Please  note  that  if you  are  a parent  or  legal  guardian  of  an emancipated  minor,  certain  portions of the emancipated minor's  medical record (or, in certain instances, the entire medical record) may not be accessible to you.

 

V.  Uses and Disclosures Requiring Your Written Authorization

 

A. Use or Disclosure with Your Authorization.   For any purpose other than those described in Section III (for which no consent or authorization is required) and Section IV (for which your consent is required), we only may use or disclose your PHI when you give us your written authorization on our authorization form ("Authorization") (an authorization form is similar to a consent form, but is more detailed and specific than a general consent form).  For instance, you will need to provide us your signed Authorization  before we can send PHI to your life insurance company, to your child’s camp or school, or to the attorney  representing the other party in litigation in which you are involved (unless the attorney has obtained a court order for such PHI).

 

B. Uses and Disclosures of Your Highly Confidential Information.    Please  refer to  Section  IV.B  above for information  about our  use and  disclosure  of your  Highly Confidential  Information.   In order  for  us to disclose  your Highly Confidential  Information for a purpose other than treatment, payment, or health care operations (for which your separate, specific consent  is required), we must obtain your separate, specific Authorization,  unless we are otherwise  permitted  by law to make such disclosure.

 

C. Marketing Communications.  We must also obtain your written authorization prior to using PHI to send you any marketing materials ("Marketing Authorization").   We can, however, provide you with marketing materials in a face-to-face encounter, without obtaining your Marketing Authorization.   We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining your Marketing Authorization.    In addition,  we may communicate  with you about products  or services  relating  to  your  treatment,  case  management  or  care  coordination,  or  alternative  treatments,  therapies, providers  or care settings  without  your Marketing  Authorization,  and we may use PHI  to identity  health-related  services and products that may be beneficial to your health and then contact you about the services and products.

 

 

VI.  Your Individual Rights

 

A. For Further Information; Complaints.    If  you  desire  further  information  about  your  privacy  rights, are concerned  that we have violated  your privacy rights or disagree  with a decision that we made about access to PHI, you may contact  our  Office  Manager.    You  may  also  file  written  complaints  with  the Director,  Office  for  Civil  Rights  of the U.S. Department of Health and Human Services.   Upon request, the Office Manager will provide you with the correct address for the Director.  We will not retaliate against you if you file a complaint with us or the Director.

 

B. Right to Request Additional Restrictions.  You may request restrictions on our use and disclosure of PHI: (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition.  All requests for such restrictions must be made in writing.   While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction.   If you wish to request additional restrictions, please obtain a request form from our Office Manager and submit the completed form to the Office Manager.  We will send you a written response.

 

C. Right to Receive Confidential Communications.   You may request, and we will accommodate any reasonable written request, to receive PHI by alternative means of communication or at alternative locations.

 

 

 

D. Right to Inspect and Copy Your Health Information.  You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records.  All requests for access must be made in writing.   Under limited circumstances, we may deny you access to your records.   If you desire access to your records, please obtain a record request form from the Office Manager and submit the completed form to the Office Manager.   If you request copies, we will charge you a reasonable fee for copying each page. Please ask the Office Manager for the fees associated with copying your records.   We will also charge you for our postage costs, if you request that we mail the copies to you.  You may also request a copy of your electronic medical record file in an electronic form.

 

E. Right to Revoke Your Authorization.   You may revoke your Authorization, your Marketing Authorization or any written authorization  obtained  in connection  with your Highly Confidential  Information,  except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Office Manager at the Practice.

F. Right to Amend Your Records.  You have the right to request that we amend PHI maintained in your medical record file or billing records.   If you desire to amend your records, please obtain an amendment request form from the Office Manager and submit the completed form to the Office Manager.   All requests for amendments must be in writing.   We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

 

G. Right to Receive An Accounting of Disclosures.   Upon written request, you may obtain an accounting of certain disclosures of PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.  If you request an accounting more than once during a twelve (12) month period, we will charge a reasonable fee for the accounting statement.

 

 H.  Right to Receive Paper Copy of this Notice.   Upon written request, you may obtain a paper copy of this Notice.

 

 I. Right to Receive Notification of a Security Breach. You have the right to be notified of a breach that compromises the security or privacy of the PHI we maintain to the extent you are affected by such breach.

 

 J. Disclosures to Health Plans. You have the right to restrict disclosures of PHI to your health plan where you have paid out-of-pocket and in full for your care.  In this situation you can instruct us not to share information about such care with your health plan.

 

VII. Effective Date and Duration of This Notice

 

A. Effective Date.  This Notice is effective on February 28, 2013.

 

B.            Right to Change Terms' of this Notice.   We may change the terms of this Notice at any time.  If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice.   If we change this Notice, we will post the revised notice in the waiting area of the Practice.  You may also obtain any revised notice by contacting the Office Manager.

 

 

VIII. Office Manager

 

You may contact the Office Manager (508) 580-3330 for further information.

 

 

 

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