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.
