Notice of Privacy Practices
Institute for Nerve Medicine
Effective Date: April 12, 2003
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.
We understand the importance of privacy and are committed
to maintaining the confidentiality of your medical information.
We make a record of the medical care we provide and may
receive such records from others. We use these records
to provide or enable other health care providers to provide
quality medical care, to obtain payment for services provided
to you as allowed by your health plan and to enable us
to meet our professional and legal obligations to operate
this medical practice properly. We are required by law
to maintain the privacy of protected health information
and to provide individuals with notice of our legal duties
and privacy practices with respect to protected health
information. This notice describes how we may use and disclose
your medical information. It also describes your rights
and our legal obligations with respect to your medical
information. If you have any questions about this Notice,
please contact our Privacy Officer listed at the end of
this document.
TABLE OF CONTENTS
A. How this Medical Practice May Use or Disclose Your
Health Information
B. When This Medical Practice May Not Use or Disclose Your
Health Information
C. Your Health Information Rights
1. Right to Request Special Privacy Protections
2. Right to Request Confidential Communications
3. Right to Inspect and Copy
4. Right to Amend or Supplement
5. Right to an Accounting of Disclosures
6. Right to a Paper Copy of this Notice
D. Changes to this Notice of Privacy Practices
E. Complaints
A. How this Medical Practice May Use or Disclose
Your Health Information
This medical practice collects health information about
you and stores it in a chart and on a computer. This is
your medical record. The medical record is the property
of this medical practice, but the information in the medical
record belongs to you. The law permits us to use or disclose
your health information for the following purposes:
1. Treatment. We use medical information about you to
provide your medical care. We disclose medical information
to our employees and others who are involved in providing
the care you need. For example, we may share your medical
information with other physicians or other health care
providers who will provide services which we do not provide.
Or we may share this information with a pharmacist who
needs it to dispense a prescription to you, or a laboratory
that performs a test. We may also disclose medical information
to members of your family or others who can help you when
you are sick or injured.
2. Payment. We use and disclose medical information about
you to obtain payment for the services we provide. For
example, we give your health plan the information it requires
before it will pay us. We may also disclose information
to other health care providers to assist them in obtaining
payment for services they have provided to you.
3. Health Care Operations. We may use and disclose medical
information about you to operate this medical practice.
For example, we may use and disclose this information to
review and improve the quality of care we provide, or the
competence and qualifications of our professional staff.
Or we may use and disclose this information to get your
health plan to authorize services or referrals. We may
also use and disclose this information as necessary for
medical reviews, legal services and audits, including fraud
and abuse detection and compliance programs and business
planning and management. We may also share your medical
information with our "business associates", such
as our billing service, that perform administrative services
for us. We have a written contract with each of these business
associates that contains terms requiring them to protect
the confidentiality of your medical information. Although
federal law does not protect health information which is
disclosed to someone other than another healthcare provider,
health plan or healthcare clearinghouse, under California
law all recipients of health care information are prohibited
from re-disclosing it except as specifically required or
permitted by law. We may also share your information with
other health care providers, health care clearinghouses
or health plans that have a relationship with you, when
they request this information to help them with their quality
assessment and improvement activities, their efforts to
improve health or reduce health care costs, their review
of competence, qualifications and performance of health
care professionals, their training programs, their accreditation,
certification or licensing activities, or their health
care fraud and abuse detection and compliance efforts.
4. Appointment Reminders. We may use and disclose medical
information to contact and remind you about appointments.
If you are not home, we may leave this information on your
answering machine or in a message left with the person
answering the phone.
5. Sign in sheet. We may use and disclose medical information
about you by having you sign in when you arrive at our
office. We may also call out your name when we are ready
to see you.
6. Notification and communication with family. We may
disclose your health information to notify or assist in
notifying a family member, your personal representative
or another person responsible for your care about your
location, your general condition or in the event of your
death. In the event of a disaster, we may disclose information
to a relief organization so that they may coordinate these
notification efforts. We may also disclose information
to someone who is involved with your care or helps pay
for your care. If you are able and available to agree or
object, we will give you the opportunity to object prior
to making these disclosures, although we may disclose this
information in a disaster even over your objection if we
believe it is necessary to respond to the emergency circumstances.
If you are unable or unavailable to agree or object, our
health professionals will use their best judgment in communication
with your family and others.
7. Marketing. We may contact you to give you information
about products or services related to your treatment, case
management or care coordination, or to direct or recommend
other treatments or health-related benefits and services
that may be of interest to you. We will not use or disclose
your medical information without your written authorization.
8. Required by law. As required by law, we will use and
disclose your health information, but we will limit our
use or disclosure to the relevant requirements of the law.
When the law requires us to report abuse, neglect or domestic
violence, or respond to judicial or administrative proceedings,
or to law enforcement officials, we will further comply
with the requirement set forth below concerning those activities.
9. Public health. We may, and are sometimes required
by law to disclose your health information to public health
authorities for purposes related to: preventing or controlling
disease, injury or disability; reporting child, elder or
dependent adult abuse or neglect; reporting domestic violence;
reporting to the Food and Drug Administration problems
with products and reactions to medications; and reporting
disease or infection exposure. When we report suspected
elder or dependent adult abuse or domestic violence, we
will inform you or your personal representative promptly
unless in our best professional judgment, we believe the
notification would place you at risk of serious harm or
would require informing a personal representative we believe
is responsible for the abuse or harm.
10. Health oversight activities. We may, and are sometimes
required by law to disclose your health information to
health oversight agencies during the course of audits,
investigations, inspections, licensure and other proceedings,
subject to the limitations imposed by federal and California
law.
11. Judicial and administrative proceedings. We may,
and are sometimes required by law, to disclose your health
information in the course of any administrative or judicial
proceeding to the extent expressly authorized by a court
or administrative order. We may also disclose information
about you in response to a subpoena, discovery request
or other lawful process if reasonable efforts have been
made to notify you of the request and you have not objected,
or if your objections have been resolved by a court or
administrative order.
12. Law enforcement. We may, and are sometimes required
by law, to disclose your health information to a law enforcement
official for purposes such as identifying of locating a
suspect, fugitive, material witness or missing person,
complying with a court order, warrant, grand jury subpoena
and other law enforcement purposes.
13. Coroners. We may, and are often required by law,
to disclose your health information to coroners in connection
with their investigations of deaths.
14. Organ or tissue donation. We may disclose your health
information to organizations involved in procuring, banking
or transplanting organs and tissues.
15. Public safety. We may, and are sometimes required
by law, to disclose your health information to appropriate
persons in order to prevent or lessen a serious and imminent
threat to the health or safety of a particular person or
the general public.
16. Specialized government functions. We may disclose
your health information for military or national security
purposes or to correctional institutions or law enforcement
officers that have you in their lawful custody.
17. Worker’s compensation. We may disclose your
health information as necessary to comply with worker’s
compensation laws. For example, to the extent your care
is covered by workers' compensation, we will make periodic
reports to your employer about your condition. We are also
required by law to report cases of occupational injury
or occupational illness to the employer or workers' compensation
insurer.
18. Change of Ownership. In the event that this medical
practice is sold or merged with another organization, your
health information/record will become the property of the
new owner, although you will maintain the right to request
that copies of your health information be transferred to
another physician or medical group.
19. Research. We may disclose your health information
to researchers conducting research with respect to which
your written authorization is not required as approved
by an Institutional Review Board or privacy board, in compliance
with governing law.
20. Fundraising. We may use or disclose your demographic
information and the dates that you received treatment in
order to contact you for fundraising activities. If you
do not want to receive these materials, notify the Privacy
Officer listed at the top of this Notice of Privacy Practices.
B. When This Medical Practice May Not Use or Disclose
Your Health Information
Except as described in this Notice of Privacy Practices,
this medical practice will not use or disclose health information
which identifies you without your written authorization.
If you do authorize this medical practice to use or disclose
your health information for another purpose, you may revoke
your authorization in writing at any time.
C. Your Health Information Rights
1. Right to Request Special Privacy Protections. You have
the right to request restrictions on certain uses and
disclosures of your health information, by a written
request specifying what information you want to limit
and what limitations on our use or disclosure of that
information you wish to have imposed. We reserve the
right to accept or reject your request, and will notify
you of our decision.
2. Right to Request Confidential Communications. You
have the right to request that you receive your health
information in a specific way or at a specific location.
For example, you may ask that we send information to a
particular e-mail account or to your work address. We will
comply with all reasonable requests submitted in writing
which specify how or where you wish to receive these communications.
3. Right to Inspect and Copy. You have the right to inspect
and copy your health information, with limited exceptions.
To access your medical information, you must submit a written
request detailing what information you want access to and
whether you want to inspect it or get a copy of it. We
will charge a reasonable fee, as allowed by California
law. We may deny your request under limited circumstances.
If we deny your request to access your child's records
because we believe allowing access would be reasonably
likely to cause substantial harm to your child, you will
have a right to appeal our decision. If we deny your request
to access your psychotherapy notes, you will have the right
to have them transferred to another mental health professional.
4. Right to Amend or Supplement. You have a right to
request that we amend your health information that you
believe is incorrect or incomplete. You must make a request
to amend in writing, and include the reasons you believe
the information is inaccurate or incomplete. We are not
required to change your health information, and will provide
you with information about this medical practice's denial
and how you can disagree with the denial. We may deny your
request if we do not have the information, if we did not
create the information (unless the person or entity that
created the information is no longer available to make
the amendment), if you would not be permitted to inspect
or copy the information at issue, or if the information
is accurate and complete as is. You also have the right
to request that we add to your record a statement of up
to 250 words concerning any statement or item you believe
to be incomplete or incorrect.
5. Right to an Accounting of Disclosures. You have a
right to receive an accounting of disclosures of your health
information made by this medical practice, except that
this medical practice does not have to account for the
disclosures provided to you or pursuant to your written
authorization, or as described in paragraphs 1 (treatment),
2 (payment), 3 (health care operations), 6 (notification
and communication with family) and 16 (specialized government
functions) of Section A of this Notice of Privacy Practices
or disclosures for purposes of research or public health
which exclude direct patient identifiers, or which are
incident to a use or disclosure otherwise permitted or
authorized by law, or the disclosures to a health oversight
agency or law enforcement official to the extent this medical
practice has received notice from that agency or official
that providing this accounting would be reasonably likely
to impede their activities.
6. You have a right to a paper copy of this Notice of
Privacy Practices, even if you have previously requested
its receipt by e-mail.
If you would like to have a more detailed explanation
of these rights or if you would like to exercise one or
more of these rights, contact our Privacy Officer listed
at the top of this Notice of Privacy Practices.
D. Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices
at any time in the future. Until such amendment is made,
we are required by law to comply with this Notice. After
an amendment is made, the revised Notice of Privacy Protections
will apply to all protected health information that we
maintain, regardless of when it was created or received.
We will keep a copy of the current notice posted in our
reception area, and will offer you a copy at each appointment.
We will also post the current notice on our website.
E. Complaints
Complaints about this Notice of Privacy Practices or how
this medical practice handles your health information
should be directed to our Privacy Officer listed below.
Institute for Nerve Medicine, Inc. Privacy Official (877)
724-6674
If you are not satisfied with the manner in which this
office handles a complaint, you may submit a formal complaint
to:
Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
You will not be penalized for filing a complaint.
