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Notice of Privacy Practices
Northside Urgent Care, LLC
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.
If
you have any questions about this Notice please contact our Privacy Officer
770-952-8899.
This Notice of Privacy Practices describes how
we may use and disclose your protected health information to carry out
treatment, payment or health care operations and for other purposes that
are permitted or required by law. It also describes your rights to access
and control your protected health information. "Protected health
information" is information about you, including demographic information,
that may identify you and that relates to your past, present or future
physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice
of Privacy Practices. We may change the terms of our notice, at any time.
The new notice will be effective for all protected health information
that we maintain at that time. Upon your request, we will provide you
with any revised Notice of Privacy Practices by calling the office and
requesting that a revised copy be sent to you in the mail, or asking for
one at the time of your next appointment.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Treatment, Payment and Healthcare Operations
Your protected health information may be used and
disclosed by your physician, our office staff and others outside of our
office that are involved in your care and treatment for the purpose of
providing health care services to you. Your protected health information
may also be used and disclosed to pay your health care bills and to support
the operation of the physician's practice.
Following are examples of the types of uses and
disclosures of your protected health care information that the physician's
office is permitted to make without your specific authorization or consent.
These examples are not meant to be exhaustive, but to describe the types
of uses and disclosures that may be made by our office.
Treatment: We will use and disclose your
protected health information to provide, coordinate, or manage your health
care and any related services. For example, we would disclose your protected
health information, as necessary, to your primary care physician or specialist
who has referred you to us. We will also disclose protected health information
to other physicians or health care providers who may be treating you.
For example, your protected health information may be provided to a physician
to whom you have been referred to ensure that the physician has the necessary
information to diagnose or treat you.
Payment: Your protected health information
will be used, as needed, to obtain payment for your health care services.
Quite simply, a bill may be sent to you or your insurance company for
payment. The information on or accompanying the bill may include information
that identifies you, as well as your diagnosis, procedures, and supplies
used. This may also include activities your insurance company may undertake
before it approves or pays for the health care services we recommend or
perform for you such as determining your eligibility for coverage or medical
necessity for the treatment For example, obtaining an approval for a MRI
diagnostic study may require that your relevant protected health information,
such as name and diagnosis, be disclosed to the insurance company to obtain
approval to perform the MRI.
Healthcare Operations: We may use or disclose,
as-needed, your protected health information in order to support the business
activities of our physicians' practice. For example, we may use a sign-in
sheet at the registration desk where you will be asked to sign your name
and time of arrival. We may also call you by name in the waiting room
when your physician is ready to see you or when it is time to perform
your test or procedure. Additionally, we may use or disclose your protected
health information, as necessary, to contact you to remind you of your
appointment.
We will also share your protected health information
with third party "business associates" that perform various
activities (e.g. billing, transcription services) for the practice. Whenever
an arrangement between our office and a business associate involves the
use or disclosure of your protected health information, we will have a
written contract that contains terms that will protect the privacy of
your protected health information.
We may use or disclose your protected health information,
as necessary, to provide you with information about treatment alternatives
or expanded services that may be of interest to you. For example, your
name and address may be used to send you a newsletter or brochure about
our practice and the services we offer. You may contact our Privacy Officer
to request that these materials not be sent to you.
Finally, we may use or disclose your personal health information in the
course of performing quality improvement activities. For example, members
of our staff may use information in your health record to assess the care
and results or outcomes in your case and others like it for quality improvement
activities.
Uses and Disclosures of Protected Health Information Based upon Your Written
Authorization
Other uses and disclosures of your protected health
information will be made only with your written authorization, unless
otherwise permitted or required by law as described below. You may revoke
this authorization, at any time, in writing, except to the extent that
your physician or the physician's practice has taken an action in reliance
on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May be Made
with your Consent, Authorization or Opportunity to Object
You have the opportunity to agree or object to
the use or disclosure of all or part of your protected health information
in the following examples.
• Others
involved in your healthcare: 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. If you are unable to
agree or object to such a disclosure, we may disclose such information
as necessary if we determine that it is in your best interest based on
our professional judgment. We may use or disclose protected health information
to notify or assist in notifying a family member, personal representative
or any other person that is responsible for your care location, general
condition or death. Finally, we may use or disclose your protected health
information to an authorized public or private entity to assist in disaster
relief efforts.
• Emergencies:
We may use or disclose your protected health information in an emergency
treatment situation.
Other Permitted and Required Uses and Disclosures That May Be Made
Without Your Consent, Authorization or Opportunity to Object
• Required
by Law: We may use or disclose your protected health information to
the extent that the use or disclosure is required by law. The use or disclosure
will be made in compliance with the law and will be limited to the relevant
requirements of the law. You will be notified, as required by law, of
any such uses or disclosures.
• Public
Health: We may disclose your protected health information for public
health activities and purposes to a public health authority that is permitted
by law to collect or receive the information. The disclosure will be made
for the purpose of controlling disease, injury or disability.
• Communicable
Diseases: We may disclose your protected health information, if authorized
by law, to a person who may have been exposed to a communicable disease
or may otherwise be at risk of contracting or spreading the disease or
condition.
• Health
Oversight: We may disclose protected health information to a health
oversight agency, such as Medicare, Medicaid, Department of Health and
Human Services, Office of Civil Rights or a managed care company for activities
authorized by law, such as audits, investigations, and inspections.
• Abuse
and Neglect: We may disclose your protected health information to
a public health authority that is authorized by law to receive reports
of child abuse or neglect. In addition, we may disclose your protected
health information if we believe that you have been a victim of abuse,
neglect or domestic violence to the governmental entity or agency authorized
to receive such information. In this case, the disclosure will be made
consistent with the requirements of applicable federal and state laws.
• Food
and Drug Administration: We may disclose your protected health information
to a person or company required by the food and Drug Administration to
report adverse events, product defects or problems, biologic product deviations,
track products; to enable product recalls; to make repairs or replacements,
or to conduct post marketing surveillance, as required.
• Legal
Proceedings: We may disclose protected health information in the course
of any judicial or administrative proceeding, in response to an order
of a court or administrative tribunal (to the extent such disclosure is
expressly authorized), in certain conditions in response to a subpoena,
discovery request or other lawful process, and according to Georgia state
law.
• Law
Enforcement: We may also disclose protected health information, so
long as applicable legal requirements are met, for law enforcement purposes.
This includes disclosing your protected health information, if we believe
that the use or disclosure is necessary to prevent or lessen a serious
and imminent threat to the health or safety of a person or the public.
We may also disclose protected health information if it is necessary for
law enforcement authorities to identify or apprehend an individual.
• Coroners,
Funeral Directors and Organ Donation: We may disclose protected health
information to a coroner or medical examiner for identification purposes,
determining cause of death or for the coroner or medical examiner to perform
other duties authorized by law.
•
Research: We may disclose your
protected health information to researchers when 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 of individuals who
are Armed Forces personnel (1) for activities deemed necessary by appropriate
military command authorities; (2) for the purpose of a determination by
the Department of Veterans Affairs of your eligibility for benefits, or
(3) to foreign military authority if you are a member of that foreign
military service.
• Workers
Compensation: Your protected health information may be disclosed by
us as authorized to comply with workers' compensation laws and other similar
legally established programs.
YOUR RIGHTS
Following is a statement of your rights with respect
to your protected health information and a brief description of how you
may exercise these rights
You have the right to inspect and copy your
protected health information. This means you may inspect and obtain
a copy of protected health information about you that is contained in
a designated record set for as long as we maintain the protected health
information. All requests for copying or inspection of your medical record
will be fulfilled within 30 days of the request. A "designated record
set" contains medical and billing records that your physician and
the practice use for making decisions about you.
Under federal law, however, you may not inspect
or copy information compiled in reasonable anticipation of, or use in,
a civil, criminal, or administrative action or proceeding. Depending on
the circumstances, a decision to deny access may be reviewable. In some
circumstances, you may have a right to have this decision reviewed. Please
contact our Privacy Officer if you have questions about access to your
medical record.
You have the right to request a restriction
of your protected health information. This means you may ask us not
to use or disclose any part of your protected health information for the
purposes of treatment, payment or healthcare operations. You may also
request that any part of your protected health information not be disclosed
to family members or friends who may be involved in your care or for notification
purposes as described in this Notice of Privacy Practices. Your request
must state the specific restriction requested and to whom you want the
restriction to apply.
Your physician is not required to agree to a restriction
that you may request. If physician believes it is in your best interest
to permit use and disclosure of your protected health information, your
protected health information will not be restricted. If your physician
does agree to the requested restriction, we may not use or disclose your
protected health information in violation of that restriction unless it
is needed to provide emergency treatment. With this in mind, please discuss
any restriction you wish to request with your physician.
You have the right to request to receive confidential
communications from us by alternative means or at an alternative location.
This request must be in writing and we will accommodate reasonable requests.
We may also condition this accommodation by asking you for information
as to how payment will be handled or specification of an alternative address
or other method of contact.
You may have the right to have your physician
amend your protected health information. This means you may request
an amendment of protected health information about you in a designated
record set for as long as we maintain this information. In certain cases,
we may deny your request for an amendment. If we deny your request for
amendment, you have the right to file a statement of disagreement with
the Privacy Officer and we may prepare a rebuttal to your statement and
will provide you a copy of any such rebuttal.
You have a right to receive an accounting of
certain disclosures we have made, if any, of your protected health information.
This right applies to disclosures for purposes other than treatment, payment
or healthcare operations as described in this Notice of Privacy Practices.
It excludes disclosures we may have made to you, to family members or
friends involved in your care, or for notification purposes. You have
the right to receive specific information regarding these disclosures
that occurred after April 14, 2003. The right to receive this information
is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of
this notice from us at any time upon request.
COMPLAINTS
You may complain to us or to the Secretary of Health
and Human Services if you believe your privacy rights have been violated
by us. You may file a complaint with us by notifying our privacy contact
of your complaint. We will not retaliate against you for filing a complaint.
You may contact our Privacy Officer, at 770-952-8899
for further information about the complaint process.
This notice was published and becomes effective
on April 14, 2003
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