Notice of Privacy Practices

Version No.2 – December 8, 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.

 

I.          Who We Are

 

            This Notice describes the privacy practices of Outpatient Imaging & Specialty Care at Camp Creek (the “Organization”), including members of its workforce, employed or contracted physicians, allied health professionals and other members of our workforce who provide services at our practice locations or otherwise on our behalf.  The Organization is, and the individual health care providers together are sometimes called "us" or "we" in this Notice.  This Notice applies to services furnished to you at Outpatient Imaging & Specialty Care at Camp Creek, or other location where we provide health care services to you.

II.          Our Privacy Obligations

            We are required by law to maintain the privacy of your health information ("Protected Health Information" or "PHI") and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information.  When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

 

 III.        Permissible Uses and Disclosures Without Your Written Authorization

 

In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI.  However, we do not need any type of authorization from you for the following uses and disclosures:

 

A.         Uses and Disclosures for Treatment, Payment and Health Care Operations.  We may use and disclose PHI, but not your “Highly Confidential Information” (defined in Section IV.C below), in order to treat you, obtain payment for services provided to you and conduct our “health care operations” as detailed below:

 

·     Treatment.  We use and disclose your PHI to provide treatment and other services to you--for example, to diagnose and treat your injury or illness.  In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.  We may also disclose PHI to other providers involved in your treatment.

 

·     Payment.  We may use and disclose your PHI to obtain payment for services that we provide to you--for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”) to verify that Your Payor will pay for health care.

 

·     Health Care Operations.  We may use and disclose your PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you.  For example, we may use PHI to evaluate the quality and competence of our physicians, nurses or other health care workers.  We may disclose PHI to our Privacy Officer in order to resolve any complaints you may have.  If we disclose your PHI to a private peer review committee, we will conform to additional requirements under Georgia law.

 

We may also disclose PHI to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.  In addition, we may share PHI with our business associates who perform treatment, payment and health care operations services on our behalf.  Notwithstanding the above, if you are a parent or guardian, we will obtain your appropriate general consent before we will use or disclose the PHI of your child for Treatment, Payment or Health Care Operations.

 

B.         Disclosure to Relatives, Close Friends and Other Caregivers.  We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure. 

 

                        If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests.  If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person's involvement with your health care or payment related to your health care.  We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location or general condition. 

 

C.         Public Health Activities.  We may disclose your PHI for the following public health activities:  (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities orother government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; (6) to report spontaneous fetal death within 10 days upon the form prescribed by the State Registrar; and (7) to report cases of bullet wounds, gunshot wound, powder burn or any other injury arising from or caused by, or appearing to arise from or be caused by, the discharge of a gun or firearm, every case or illness apparently caused by poisoning, every case of a wound or injury caused, or apparently caused, by a knife or sharp or pointed instrument if it appears to the physician treating the case that a criminal act was involved, and every case of a wound, injury or illness in which there is grave bodily harm or grave illness if it appears to the physician treating the case that the wound, injury or illness resulted from a criminal act of violence.   Notwithstanding the above, we will report the following named diseases, injuries and illnesses to the appropriate Georgia public health authorities within 15 days: (i) asbestosis; (ii) silicosis; (iii) elevated blood lead levels for adults; and (iv) serious and preventable injuries caused by tractors, farm equipment or farm machinery that occur while working on a farm.

 

D.         Victims of Abuse, Neglect or Domestic Violence.  If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence. 

 

E.         Health Oversight Activities.  We may disclose your PHI to the Georgia Commission for Health Services or another health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

 

F.         Judicial and Administrative Proceedings.  We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process as permitted under Georgia law.

 

G.         Law Enforcement Officials.  We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena. 

 

H.         Decedents.  We may disclose your PHI to a coroner or medical examiner as authorized by law.

 

I.          Organ and Tissue Procurement.  We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

 

J.         Research.  We may use or disclose your PHI without your consent or authorization if our Institutional Review Board or Privacy Board approves a waiver of authorization for disclosure or we release records which pertain to communicable disease or communicable condition research and we follow other requirements of Georgia law.]

 

K.         Health or Safety.  We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person's or the public's health or safety as permitted or required under Georgia law.

 

L.         Specialized Government Functions.  We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

 

M.        Workers' Compensation.  We may disclose your PHI as authorized by and to the extent necessary to comply with Georgia law relating to workers' compensation or other similar programs.

 

N.         As Required by Law.  We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.

 

IV.        Uses and Disclosures Requiring Your Written Authorization

 

A.         Use or Disclosure with Your Authorization.  For any purpose other than the ones described above in Section III, we only may use or disclose your PHI when you grant us your written authorization on our authorization form (“Your Authorization”).  For instance, you will need to execute an authorization form before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved. 

 

B.         Marketing.  We must also obtain your written authorization (“Your Marketing Authorization”) prior to using your PHI to send you any marketing materials.  We may, however, provide you with marketing materials in a face-to-face encounter without obtaining Your Marketing Authorization.  We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining Your Marketing Authorization.  In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.

 

C.         Uses and Disclosures of Your Highly Confidential Information.  In addition, federal and state law require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that:  (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities or part of Georgia Mental Health Programs; (3) is about alcohol and drug abuse prevention, treatment, and referral; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is any list of names or other information concerning any patient applying for or receiving Medicaid (except for purposes directly connected with the administration of the Medicaid Program); or (6) is PHI that is owned by the Division of Medical Assistance or the county departments of social services. In order for us to disclose your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written authorization. 

 

            For uses or disclosures of information of mental health, such authorization shall include: (1) client's name; (2) name of facility releasing the information; (3) name of individual or individuals, agency or agencies to whom information is being released; (4) information to be released; (5) purpose for the release; (6) length of time authorization is valid; (7) a statement that the authorization is subject to revocation at any time except to the extent that action has been taken in reliance on the consent; (8) signature of the client or the client's legally responsible person; and (9) date authorization is signed.  Except in limited circumstances, such authorization shall be valid for a period not to exceed one year.

 

For uses or disclosures of PHI that is owned by the Division of Medical Assistance or the county departments of social services, such authorization be on the form provided by the Division of Medical Assistance or shall include: (1) name of provider and the recipient of the information; (2) the extent of the information to be released; (3) the name and dated signature of the client; (4) a statement that the authorization is subject to revocation at any time except to the extent that action has been taken in reliance on the authorization; and (5) the length of time the authorization is valid.

 

V.         Your Rights Regarding Your Protected Health Information

 

A.         For Further Information; Complaints.  If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact the Privacy Officer.  You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services.  Upon request, the Privacy Officer will provide you with the correct address for the Director.  We will not retaliate against you if you file a complaint with us or the Director. 

 

B.         Right to Request Additional Restrictions.  You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition.  While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction.  If you wish to request additional restrictions, please obtain a request form from the Privacy Officer and submit the completed form to the Privacy Officer.  We will send you a written response.

 

C.         Right to Receive Confidential Communications.  You may request, and we will accommodate, any reasonable writtenrequest for you to receive your PHI by alternative means of communication or at alternative locations. 

 

D.         Right to Revoke Your Authorization.  You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Officer identified below. 

 

E.         Right to Inspect and Copy Your Health Information.  You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records.  Under limited circumstances, we may deny you access to a portion of your records.  If you desire access to your records, please obtain a record request form from the Privacy Officer and submit the completed form to the Privacy Officer.  If you request copies, we will charge you $0.93 per page for the first 20 pages, $0.80 per page for the 21st through 100th page; and $0.63 per page for any remaining pages of the provided copies.  We will also charge you for our postage costs, if you request that we mail the copies to you.

 

F.         Right to Amend Your Records.  You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records.  If you desire to amend your records, please obtain an amendment request form from the Privacy Officer and submit the completed form to the Privacy Officer.  We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

 

G.         Right to Receive an Accounting of Disclosures.  Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.  If you request an accounting more than once during a twelve (12) month period, there will be a charge for each additional accounting statement. 

 

H.         Right to Receive Paper Copy of this Notice.  Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically. 

 

VI.        Effective Date and Duration of This Notice

 

A.         Effective Date.  This Notice is effective as of February 17, 2009.

 

B.         Right to Change Terms of this Notice.  We may change the terms of this Notice at any time.  If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice.  If we change this Notice, we will post the new notice in the waiting areas of our practice locations.  You also may obtain any new notice by contacting the Privacy Officer.

 

VII.       Privacy Officer

 

You may contact the Privacy Officer at:

 

            Privacy Officer

South Fulton Medical Center     

1170 Cleveland

            East Point, GA 30344

            Telephone Number: 404.466.1120

 

Corporate Privacy Office

Tenet HealthSystem

13737 Noel Road, Suite 100

Dallas, Texas  75240

E-mail:  PrivacySecurityOffice@tenethealth.com

            Ethics Action Line (EAL): 1-800-8-ETHICS

 

 

 





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