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.
WHO WILL FOLLOW THIS NOTICE
This notice describes
our practice and that of:
Any health care professional
authorized to enter information into your office chart;
departments and units of this office practice, including DigestiveCare
Endoscopy Unit (DEU)
member of a volunteer group we allow to help you while you are in
the office, or DEU;
Any medical student,
intern, resident or fellow that we allow to help you while you are
in the office, or DEU;
representative of an insurance carrier, managed care organization,
clinical research organization, data analysis organization, or quality
improvement organization that is participating in a review of your
employees, staff and other office personnel; and,
All other entities,
sites and locations where the health care professionals in this office
practice and follow the terms of this notice. In addition, these entities,
sites and locations may share medical information with each other
for treatment, payment or operations purposes as described in this
Version 1.0; April 14, 2003
OUR PLEDGE REGARDING
We are required by law
sure that medical information that identifies you is kept private;
you this notice of our legal duties and privacy practices with respect
to medical information about you; and
the terms of the notice that is currently in effect.
Treatment - We
may use medical information about you to provide you with medical treatment
or services. We may disclose medical information about you to doctors,
nurses, technicians, medical students, or other office personnel who
are involved in taking care of you at the office. For example, a doctor
treating you for a broken leg may need to know if you have diabetes
because diabetes may slow the healing process. In addition, the doctor
may need to tell the dietitian if you have diabetes so that we can arrange
for you to receive information regarding appropriate meals. Different
departments of the office also may share medical information about you
in order to coordinate the different things you need, such as prescriptions,
lab work and x-rays. We may also disclose medical information about
you to people outside the office who may be involved in your medical
care after you leave the office, such as family members, clergy or others
we use to provide services that are part of your care.
- We may use and disclose medical information about you so that the
treatment and services you receive at the office, hospital, ambulatory
surgery center, nursing home or other site may be billed to and payment
may be collected from you, an insurance company or a third party. For
example, we may need to give your health plan information about the
services you received at the office, hospital or ambulatory surgery
center, so that your health plan will pay us or reimburse you for the
services. We may also tell your health plan about a treatment you are
going to receive to obtain prior approval or to determine whether your
plan will cover the treatment.
Health Care Operations - We may use and disclose medical information about you for
office operations. These uses and disclosures are necessary to run the
office and make sure that all of our patients receive quality care.
For example, we may use medical information to review our treatment
and services and to evaluate the performance of our staff in caring
for you. We may also combine medical information about many office patients
to decide what additional services the office should offer, what services
are not needed, and whether certain new treatments are effective. We
may also disclose information to doctors, nurses, technicians, medical
students, and other office personnel for review and learning purposes.
We may also combine the medical information we have with medical information
from other offices to compare how we are doing and see where we can
make improvements in the care and services that we offer. We may remove
information that identifies you from this set of medical information
so others may use it to study health care and health care delivery without
learning who the specific patients are.
Appointment Reminders - We may use and disclose medical information to contact you
as a reminder that you have an appointment for treatment or medical
care at the office.
Treatment Alternatives - We may use and disclose medical information
to tell you about or recommend possible treatment options or alternatives
that may be of interest to you.
Health-Related Benefits and Services - We may use and disclose medical information
to tell you about health-related benefits or services that may be of
interest to you.
Ambulatory Surgery Center Directory - If we have a facility directory, we may
use and disclose your name, the location of where you are receiving
your care and a general description of your condition. All of this information
will be given to individuals who may request information about you.
For instance, if someone calls and gives your name and asks for information
about you, we will tell them where you are receiving care and a general
description of your condition. You may request that your name not be
placed in a facility and we will honor your request.
Individuals Involved in Your Care or Payment for Your Care
- Unless otherwise instructed and directed by you, we may release medical
information about you 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 your condition
and that you are in the hospital, ambulatory surgery center or office.
In addition, we may disclose medical 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.
- Under certain circumstances, we may use and disclose medical information
about you for research purposes. For example, a research project may
involve comparing the health and recovery of all patients who received
one medication to those who received another, for the same condition.
All research projects, however, are subject to a special approval process.
This process evaluates a proposed research project and its use of medical
information, trying to balance the research needs with patients' need
for privacy of their medical information. Before we use or disclose
medical information for research, the project will have been approved
through this research approval process. We may, however, disclose medical
information about you to people preparing to conduct a research project,
for example, to help them look for patients with specific medical needs,
so long as the medical information they review does not leave the office.
We will almost always ask for your specific 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.
As Required By Law - We will disclose medical information about you when required
to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety - We may use and disclose medical 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.
Any disclosure, however, would only be to someone able to help prevent
Military and Veterans - If you are a member of the Armed Forces, we may release
medical information about you as required by military command authorities.
We may also release medical information about foreign military personnel
to the appropriate foreign military authority.
Workers' Compensation - We may release medical 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 medical information about you for public
health activities. These activities generally include the following:
prevent or control disease, injury or disability;
report births and deaths;
report child abuse or neglect;
report reactions to medications or problems with products;
notify people of recalls of products they may be using;
notify a person who may have been exposed to a disease or may be at
risk for contracting or spreading a disease or condition; and,
notify the appropriate government authority if we believe a patient
has been the victim of abuse, neglect or domestic violence. We will
only make the disclosure if you agree or when required or authorized
by law. We will notify you of this unless it is in our good faith
belief that such notification would put you or others at serious risk
Health Oversight Activities - We may disclose medical information to
a health oversight agency for activities authorized by law. These oversight
activities include, for example, audits, investigations, inspections,
and licensure. These activities are necessary for the government 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
medical information about you in response to a court or administrative
order. We may also disclose medical information about you in response
to a subpoena, discovery request, or other lawful process by someone
else involved in the dispute, but only if efforts have been made to
tell you about the request or to obtain an order protecting the information
- We may release medical information if asked to do so by a law-enforcement
response to a court order, subpoena, warrant, summons or similar process;
identify or locate a suspect, fugitive, material witness, or missing
the victim of a crime if, under certain limited circumstances, we
are unable to obtain the person's agreement;
a death we believe may be the result of criminal conduct;
criminal conduct at the office or ambulatory surgery center; and
emergency circumstances to report a crime; the location of the crime
or victims; or the identity, description or location of the person
who committed the crime.
may also disclose PHI in response to law enforcement officials, however,
such information will be limited to that required by 45 C.F.R. Section
164.512 (f) (2).
Coroners, Medical Examiners and Funeral Directors - We may release medical information to
a coroner or medical examiner. This may be necessary, for example, to
identify a deceased person or determine the cause of death. We may also
release medical information about patients to funeral directors as necessary
to carry out their duties.
National Security and Intelligence Activities - We may release medical information about
you to authorized federal officials for intelligence, counterintelligence,
and other national security activities authorized by law.
Protective Services for the President and Others - We may disclose medical information about
you to authorized federal officials so they may provide protection to
the President, other authorized persons or foreign heads of state or
conduct special investigations.
Governmental Departments - We may use and disclose protected health
information about you to various governmental functions such as military
missions, eligibility for veterans benefits, national security activity,
protective services concerning executive officials or to determine suitability
for security clearance or service abroad.
- If you are an inmate of a correctional institution or under the custody
of a law enforcement official, we may release medical information about
you to the correctional institution or law enforcement official. This
release would be necessary (1) for the institution to provide you with
health care; (2) to protect your health and safety or the health and
safety of others; or (3) for the safety and security of the correctional
YOUR RIGHTS REGARDING
MEDICAL INFORMATION ABOUT YOU
You have the following
rights regarding medical information we maintain about you:
Right to Inspect and Copy - You have the right to inspect and copy
medical information that may be used to make decisions about your care.
Usually, this includes medical and billing records, but does not include
To inspect and copy medical information
that may be used to make decisions about you, you must submit your request
in writing to DigestiveCare.
If you request a copy of the information, we may charge a fee as permitted
by state law for the costs of copying, mailing or other supplies associated
with your request.
We may deny
your request to inspect and copy in certain very limited circumstances.
If you are denied access to medical information, you may request that
the denial be reviewed. Another licensed health care professional chosen
by the office will review your request and the denial. The person conducting
the review will not be the person who denied your request. We will comply
with the outcome of the review.
Right to Amend
- If you feel that medical 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
by or for the office.
To request an
amendment, your request must be made in writing and submitted to DigestiveCare. 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:
not created by us, unless the person or entity that created the information
is no longer available to make the amendment;
not part of the medical information kept by or for the office;
not part of the information which you would be permitted to inspect
and copy; or,
accurate and complete.
If your request is denied, the denial will
clearly state the actual reason(s) why the request was denied and what
rights you have in the event this action occurs.
Right to an Accounting of Disclosures - You have the right to request an "accounting
of disclosures." This is a list of the disclosures we made of medical
information about you.
To request this
list or accounting of disclosures, you must submit your request in writing
Your request must state a time-period that 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 medical 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 medical information we disclose about
you to someone who is involved in your care or the payment for your
care, like a family member or friend. For example, you could ask that
we not use or disclose information about a surgery that you had.
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. To request
restrictions, you must make your request
in writing to DigestiveCare.
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
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.
To request confidential communications,
you must make your request in writing to DigestiveCare. 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 or Electronic 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 this notice electronically,
you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at
our web site, http://www.digestivecare.net.
To obtain a paper copy of this notice, contact:
Craig Penno, Administrator, DigestiveCare,
75 Sylvania Dr., Beavercreek, OH 45440, (937) 320-5050
CHANGES TO THIS NOTICE
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 in the office. The notice will contain on the first
page, in the top right-hand corner, the effective date. In addition,
each time you register at or are seen at the office for treatment or
health care services as an outpatient, we will offer you a copy of the
current notice in effect.
If you believe your privacy rights have
been violated, you may file a complaint with the office or with the
Secretary of the Department of Health and Human Services. To file a
complaint with the office, contact
Craig Penno, Administrator, DigestiveCare,
75 Sylvania Dr., Beavercreek, OH 45440.
All complaints must be submitted in writing.
You will not be penalized
for filing a complaint.
OTHER USES OF
Other uses and disclosures of medical information
not covered by this notice or the laws that apply to us will be made
only with your written permission. If you provide us permission to use
or disclose medical information about you, you may revoke that permission,
in writing, at any time. If you revoke your permission, we will no longer
use or disclose medical information about you for the reasons covered
by your written authorization.
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.
This Notice is also available for download in the following formats: