THIS DOCUMENT IS A TEMPLATE ONLY. IT DOES NOT REFLECT THE REQUIREMENTS OF YOUR STATE’S LAWS. YOU SHOULD CONSULT WITH ADVISORS (YOUR STATE OR LOCAL MEDICAL OR SPECIALTY SOCIETY, ASSOCIATION OR LEGAL OR OTHER COUNSEL) FAMILIAR WITH YOUR STATE’S PRIVACY LAWS PRIOR TO USING THIS DOCUMENT.
ATHENS BONE AND JOINT ORTHOPEDIC CLINIC, PC
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
Effective Date: 07/29/2013
If you have any questions about this notice, please contact the Athens Bone and Joint Orthopedic Clinic’s Privacy Officer at Taylor Miller (706) 583-9000 or (706) 395-1677.
This notice describes the practices of:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive from Athens Bone and Joint Orthopedic Clinic. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care and billing for that care that are generated or maintained by Athens Bone and Joint Orthopedic Clinic, whether made by Athens Bone and Joint Orthopedic Clinic personnel or other health care providers. Other health care providers may have different policies or notices about confidentiality and disclosure that apply to your medical information that is created in their offices or at locations other than Athens Bone and Joint Orthopedic Clinic.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your medical information.
We are required by law to:
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories.
If you do not want Athens Bone and Joint Orthopedic Clinic to contact you for fundraising efforts, you must notify Athens Bone and Joint Orthopedic Clinic’s Privacy Officer in writing. If you have not already done so, we must ask you each time we contact you for fundraising efforts if you wish to opt out of all future fundraising communications. If you do opt out of future fundraising communications, we will no longer disclose your information for fundraising purposes. However, in the future you may let us know in writing that you would like to receive these fundraising communications. Your decision whether or not to receive targeted fundraising materials from us will have no impact on your access to health care services or the treatment we provide to you.
Even if you have opted-out, we may send you non-targeted fundraising materials that are sent out to the general community and are not based on information from your treatment.
You have the following rights regarding medical information we maintain about you:
If we have all or any portion of your medical information in an electronic format, you may request an electronic copy of those records or request that we send an electronic copy to any person or entity you designate in writing.
Your medical information is contained in records that are the property of Athens Bone and Joint Orthopedic Clinic. To inspect or receive a copy of medical information that may be used to make decisions about you, you must submit your request in writing to Athens Bone and Joint Orthopedic Clinic’s Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request, and we may collect the fee before providing the copy to you. If you agree, we may provide you with a summary of the information instead of providing you with access to it, or with an explanation of the information instead of a copy. Before providing you with such a summary or explanation, we first will obtain your agreement to pay and will collect the fees, if any, for preparing the summary or explanation.
To request an amendment, make your request in writing to Athens Bone and Joint Orthopedic Clinic’s Privacy Officer. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it 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 amend information that:
If we deny your request for an amendment, you may submit a written statement of disagreement and ask that it be included in your medical record.
To request this list or accounting of disclosures, submit your request in writing to Athens Bone and Joint Orthopedic Clinic’s Privacy Officer and state whether you want the list on paper or electronically. Your request must state a time period that may not be longer than six years. 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. We may collect the fee before providing the list to you.
We are not required to agree to your request, with the exception of restrictions on disclosures to your health plan, as described below. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
To request restrictions, make your request in writing to Athens Bone and Joint Orthopedic Clinic’s Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
You may request that we not disclose your medical information to your health insurance plan for some or all of the services you receive during a visit to any Athens Bone and Joint Orthopedic Clinic location. If you pay the charges for those services you do not want disclosed in full at the time of such service, we are required to agree to your request. “In full” means the amount we charge for the service, not your copay, coinsurance, or deductible responsibility when your insurer pays for your care. Please note that once information about a service has been submitted to your health plan, we cannot agree to your request. If you think you may wish to restrict the disclosure of your medical information for a certain service, please let us know as early in your visit as possible.
To obtain a paper copy of this notice, request a copy from Athens Bone and Joint Orthopedic Clinic’s Privacy Officer in writing.
We reserve the right to change this notice. We reserve the right 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 a copy of the current notice at Athens Bone and Joint Orthopedic Clinic’s office. The notice will contain the effective date on the first page, in the top right-hand corner. If the notice changes, a copy will be available to you upon request.
We will investigate any discovered unauthorized use or disclosure of your medical information to determine if it constitutes a breach of the federal privacy or security regulations addressing such information. If we determine that such a breach has occurred, we will provide you with notice of the breach and advise you what we intend to do to mitigate the damage (if any) caused by the breach, and about the steps you should take to protect yourself from potential harm resulting from the breach.
If you believe your privacy rights have been violated, you may file a complaint with Athens Bone and Joint or with the Secretary of the United States Department of Health and Human Services. To file a complaint with Athens Bone and Joint Orthopedic Clinic, contact Athens Bone and Joint Orthopedic Clinic’s Privacy Officer by mail at 1010 Prince Avenue Suite 115 South, Athens GA, 30606. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
Other uses and disclosures of medical information not covered by this notice may be made only with your written authorization or as required by law. If you authorize us to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. Your revocation will be effective as of the end of the day on which you provide it in writing to Athens Bone and Joint Orthopedic Clinic’s Privacy Officer. If you revoke your permission, we will no longer use or disclose medical information about you for the purposes that you previously had authorized in writing. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
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