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.
This Notice of Privacy Practices is provided to you as a requirement of the Health Information Portability and Accountability Act (HIPAA). It describes how National Spine & Pain Centers may use or disclose your protected health information, and with whom that information may be shared. This notice also describes your rights regarding your protected health information.ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE
Please sign the Acknowledgement of Receipt of this notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care services will in no way be conditioned upon your signed acknowledgement.
OUR DUTIES TO YOU REGARDING PROTECTED HEALTH INFORMATION
“Protected health information” is individually identifiable health information that relates to your past, present, or future physical or mental health or condition, the provision of health care to you, or the payment of such health care. It includes certain demographic information, such as your age, address, and e-mail address, which we maintain about you.
We are required by law to (1) maintain the privacy of your protected health information; (2) give you this notice of our legal duties and privacy practices related to the use and disclosure of your protected health information; (3) follow the terms of the notice currently in effect; and (4) communicate any changes in the notice to you. We reserve the right to change this notice. Its effective date is at the top of the first page and at the bottom of the last page. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. If we change this notice, we will make a current copy of the notice available at our office and website treatingpain.com. You may also obtain a copy of this notice by contacting our Privacy Officer to requesting that a copy be mailed to you, or by asking for a copy at your next appointment.
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
Required Uses and Disclosures
By law, we must disclose your protected health information to you or someone who has the legal right to act on your behalf unless it has been determined by a competent medical authority that it would be harmful to you. We must also disclose health information to the Secretary of the Department of Health and Human Services (HHS) for investigations or determinations of our compliance with laws to protect the privacy of your protected health information.
Treatment, Payment and Health Care Operations
We may use and disclose your protected health information to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we may disclose your protected health information, as necessary from time-to-time to another physician or health care provider (e.g. a specialist, pharmacist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment. We may also use your protected health information to process on-line prescription refill requests.
We may use your protected health information, as needed, to obtain payment for your health care services. This may require us to disclose your protected health information to your insurance carrier in order for the carrier to approve or pay for the health care services recommended for you such as determining eligibility or coverage for benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. This may also include disclosing your relevant protected health information in order to obtain approval for a hospital stay.
Health Care Operations
We may use or disclose, as needed, your protected health information to support our daily business activities related to your health care. These activities include, but are not limited to, quality assessment activities, review of our services or staff performance reviews, performing auditing functions, resolving internal grievances, licensing, conducting or arranging for other health care related activities and uses specifically authorized by law.
We may use or disclose your protected health information, as necessary, to contact you or to remind you of your appointment.
Treatment Alternatives and Health-Related Benefits and Services
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that might interest you subject to limits imposed by law. For example, your name, address and email may be used us to send you a newsletter about the services we offer. We may also send you information about practices or ancillary services that we believe might benefit you.
Other Permitted and Required Uses and Disclosures
We may also use or disclose your protected health information for the following purposes in certain circumstances:
Required by Law
We may use or disclose your protected health information if law or regulation requires the use or disclosure.
We may share your protected health information with third-party “business associates” who perform various activities (for example, billing, transcription services) for us if the information is necessary for such functions or services. The business associates will also be required to protect your protected health information.
Individuals Involved in Your Health Care
Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. We may also give information to someone who helps pay for your care. Additionally, we may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person who is responsible for your care, of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity in disaster relief efforts for the purpose of coordinating with such organizations to locate a family member or other individuals involved in your health care.
Public Health Risks
We may disclose your protected health information for public health activities as permitted by law. The disclosure may be necessary to (1) prevent or control disease, injury or disability; (2) report births and deaths; (3) report child abuse or neglect; or (4) notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. In addition, we may disclose your protected health information to a person or company required by the Food and Drug Administration to (1) report adverse events, such as reactions to medications or product defects; (2) track products; (3) enable product recalls; (4) make repairs or replacement; and (5) conduct post-marketing surveillance as required.
Abuse, Neglect or Domestic Violence
We may disclose protected health information to notify an authorized government authority if we believe a patient has been the victim of abuse, neglect or domestic abuse.
Health Oversight Agencies
We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, licensure, and inspections. These health oversight agencies might include government agencies that oversee the health care system, government benefit programs, and other government regulatory programs.
We may disclose protected health information for a judicial or administrative proceeding, in response to an order by a court or administrative tribunal, and in certain conditions in response to a subpoena, discovery request, or other lawful process.
We may disclose protected health information for law enforcement purposes, including (1) responses to legal proceedings; (2) information requests for identification and locations; (3) circumstances pertaining to victims of a crime; (4) deaths suspected from criminal conduct; (5) crimes occurring at our site; and (6) medical emergencies (not on our premises) believed to result from criminal conduct.
Coroners, Funeral Directors and Organ Donations
We may disclose protected health information to coroners or medical examiners for identification to determine the cause of death or for the performance of other duties authorized by law. We may also disclose protected health information to funeral directors as authorized by law. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donations.
We may disclose your protected health information to researchers when authorized by law, for example, if their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Military Activity and National Security
When the appropriate conditions apply, we may use or disclose protected health information on individuals who are Armed Forces personnel (1) for activities believed necessary by appropriate military command authorities to ensure the proper execution of the military mission including determination of fitness for duty (2) for determination by the Department of Veteran Affairs (VA) of eligibility for benefits; or (3) to a foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information to authorized Federal officials for conducting national security and intelligence activities including protective services to the President or others.
We may disclose your protected health information to comply with workers’ compensation laws and other similar legally established programs.
We may use or disclose your protected health information if you are an inmate of a correctional facility if 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 facility.
We may use your contact information to provide you with notice of an unauthorized access, use, disclosure, or acquisition of your health information.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION REQUIRING YOUR PERMISSION
For any other activity or purpose not listed in this Notice of Privacy Practices, we must obtain your written permission (authorization) prior to using or sharing your protected health information. If you provide a written authorization and you change your mind, you may revoke your authorization in writing at any time. Once an authorization has been revoked, we will no longer use or share the protected health information as outlined in the authorization form; however, you should be aware that we may not be able to retract a use or disclosure that was previously made on a valid authorization.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You may exercise the following rights by submitting a written request or electronic message to our Privacy Officer at the address provided in the “Contact Information” section of this notice. Please be aware that in certain circumstances, when permitted by law, we may deny your request; however, you may be able in certain instances to seek a review of any such denial.
Right to Inspect and Copy
You may inspect and obtain a copy of your protected health information that is contained in a “designated record set” for as long as we maintain the protected health information. A designated record set contains medical and billing records and any other records that we use for making decisions about you.
If you request a copy of your designated record set, a fee for the costs of the copying, mailing or other associated supplies may be charged. Under certain circumstances, we may deny your request to inspect or obtain a copy of your protected health information. If we deny your request, we will notify you in writing and may provide you the option to have the denial reviewed.
If we maintain an electronic health record containing your protected health information and we are required to comply with the new federal privacy requirements related to electronic access, you will have the right to request that we send a copy of your protected health information in an electronic format to you or to a third party that you identify. We may charge a reasonable fee for sending the electronic copy of your protected health information.
Right to Request Restrictions
You may ask us to restrict our uses or disclosures of your protected health information for treatment, payment or health care options. You also have the right to ask to restrict disclosures to family members or others who are involved in your health care or payment for your health care. Your request must be made in writing to our Privacy Officer. In your request, you must tell us (1) what information you want restricted; (2) whether you want to restrict our use, disclosure or both; (3) to whom you want the restriction to apply, for example, disclosures to your spouse; and (4) an expiration date. We are not required to agree to any requested restriction.
Right to Request Confidential Communications
You may request that we communicate with you using alternative means or at an alternative location. We will not ask you the reason for your request. We will accommodate reasonable requests, when possible.
Right to Restrict Certain Disclosures to Health Plans
You may request that in certain circumstances we not send protected health information to health plans if the protected health information concerns a health care item or service you have paid for out-of-pocket.
Right to Request Amendment
If you believe that the information we have about you is incorrect or incomplete, you may request an amendment to your protected health information as long as we maintain this information. While we will accept requests for amendment, we may deny the amendment request in certain circumstances.
Right to Request an Accounting of Disclosures
You have a right to an accounting of certain disclosures of your health information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) for treatment, payment, and health care operations purposes; (ii) to you or your personal representative; (iii) pursuant to your authorization; (iii) to correctional institutions or law enforcement officials; and (iv) other disclosures for which federal law does not require us to provide an accounting.
Right to Obtain a Copy of this Notice
You may obtain a paper copy of this notice from us upon request at any time, even if you have agreed to receive this Notice electronically. You may also view this notice electronically on our web site, listed in the “Contact Information” section of this Notice.
OTHER APPLICABLE LAWS
This Notice of Privacy Practices is provided to you as a requirement of HIPAA. There are other federal and state privacy laws that may apply and limit our ability to use and disclose your protected health information beyond what we are allowed to do under HIPAA. Below is a list of the categories of protected health information that are subject to these more restrictive laws and a summary of those laws. These laws have been taken into consideration in developing our policies of how we will use and disclose your protected health information.
Alcohol and Drug Abuse
We are allowed to use and disclose alcohol and drug abuse information without your permission under certain limited circumstances, and/or disclose only to specific recipients.
Restrictions apply to the use and/or retention of HIV/AIDS information.
We are allowed to use and disclose mental health information without your permission under certain limited circumstances, and/or disclose only to specific recipients.
Some state laws concerning minors permit or require disclosure of protected health information to parents, guardians, and persons acting in a similar legal status. We will act consistently with the law of the state where the treatment is provided and will make disclosures following such state laws.
If you believe these privacy rights have been violated, you may file a written complaint with our Privacy Officer at the address provided in the “Contact Information” section of this notice or HHS. No retaliation will occur against you for filing a complaint.
For further information about the complaint process, or for further explanation of this document, contact:
Global Pain Management, LLC
8055 Ritchie Highway, Suite 101
Pasadena, MD 21122