Effective Date: 5/23/2017 • Revised Date: 8/24/2021
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 of Privacy Practices (“Notice”), please contact: Privacy Officer: Timothy Burke
Phone Number/E-Mail: 424-299-4598 / email@example.com
We are required by law to maintain the privacy of your protected health information (“PHI”), to provide you with notice of our legal duties and privacy practices with respect to your PHI, and to notify you in the event of a breach of your unsecured PHI. This Notice describes your rights and our obligations for using and disclosing your PHI.
You have the right to:
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we’ve shared your information
- Get a copy of this Notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
- When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help ensure your rights are maintained appropriately.
- Get an electronic or paper copy of your medical record
- You have the right to view, inspect and receive electronic or paper copies of your PHI, including your medical record.
- You will not be charged to view and inspect your medical record, but we may charge a reasonable, cost-based fee for copying your medical record. If you would like your record copied, whether in paper or electronic form, you must agree in advance to the copying charge.
- In certain circumstances, we may deny access to your medical record. If so, we will notify you of our denial in writing and we will explain to you why your request to view or copy your medical record was denied.
Notice of Privacy Practices
In certain circumstances, you may ask for an appeal to have our denial reviewed by another health care professional. If we deny your request to review your medical record, you may ask for an appeal if our denial is for the following reasons:
- We have determined that access to the record would endanger the life or physical safety of you or another person.
- We have determined that the medical record makes reference to another person and that access to the record may cause substantial harm to that person.
- The request for access to the medical record was made by your personal representative and we have determined that access to the record could cause harm to you or to another person.
- If we deny your request for certain other reasons, you are not entitled to an appeal. These reasons are:
- The requested record is not part of a designated record set.
- The requested record contains psychotherapy notes.
- The requested record was put together in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding.
- The requested record is subject to the Clinical Laboratory Improvement Amendments or the federal Privacy Act and access is prohibited by those laws.
- The requested record is about an inmate in a correctional facility.
- The requested record is being used in a research study and you were advised prior to agreeing to participate in the study that access to your PHI would be prohibited during the study.
- The requested record was obtained from someone other than a health care provider and access to the record would violate a promise of confidentiality that was made to the person or organization that provided the information.
- If you wish to inspect your medical records, you must make a written request. A simple letter addressed to our local practice director, whose name you can obtain from your treating Radiologist, is all that is needed. We will respond within 30 days of receiving your request in accordance with federal law. However, we are permitted to have one 30-day extension of time to consider your request, as long as we inform you of the need and the reason for the extension. In the event state law requires us to respond earlier than 30 days, we will make every effort to adhere to those shorter response times. Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. A simple letter addressed to our local practice director, whose name you can obtain from your treating Radiologist, is all that is needed.
- We may say “no” to your request, but we’ll tell you why in writing within 30 days.
- Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
Notice of Privacy Practices
Special Notice on E-Mail: You may find it convenient to communicate with us by e- mail. We may communicate with you by e-mail if you so request or if you initiate e- mail communication with us. However, e-mail communications originating from you may not be encrypted and thus not secure. E-mail originating from us will be encrypted. We cannot protect the confidentiality of your PHI while it is being transmitted over the Internet and cannot guarantee email received from you that may be forwarded will be appropriately encrypted.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months of a previous request. Get a copy of this Notice
- You, and any member of the public, can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. We will provide you with a paper copy promptly.
- We will use reasonable efforts to obtain your acknowledgment of receipt of the Notice, and such acknowledgment may be in the form of your initials on a cover sheet or your signature on a list or other form. The acknowledgment may also be electronic. If we are unable to obtain your acknowledgment of receipt of this Notice, we are still required to provide you with access to your PHI if requested as set forth in this Notice. Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will take appropriate steps to ensure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated
- Our Privacy Officer is listed at the top of this Notice and serves as the contact person for individuals who have complaints about how the Practice has used or disclosed their PHI or who have questions about the Practice’s Notice. You can complain if you feel we have violated your rights by contacting the Privacy Officer.
Notice of Privacy Practices
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- The Practice nor any of our teammates will take any action to retaliate against you for filing a complaint. Your Choices You have some choices in the way that we use and share information when we:• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise fundsFor certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directoryIf you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.Unless you give us written permission, we will never:
• Use your information for marketing purposes
• Sell your information
• Disclose psychotherapy notes in most instances
• Use your information to respond to organ or tissue donor requestsIn the case of fundraising:
We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
We may use and share your information when we:
- Treat you
- Run our organization
- Bill for your services
- Help with public health and safety issues • Conduct research
Notice of Privacy Practices
- Comply with the law
- Respond to organ and tissue donation requests
- Work with a medical examiner or funeral director
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions. We typically use or share your health information in the following ways.
- We can use your health information and share it with other professionals who are treating you.
- Example: A doctor treating you for an injury asks another doctor about your overall health condition.Run our organization
- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
- Example: We use health information about you to manage your treatment and services.Bill for your services
- We can use and share your health information to bill and get payment from health plans or other entities.
- Example: We give information about you to your health insurance plan so it will pay for your services. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety. Conduct research. We can use or share your information for health research. Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.Work with a medical examiner or funeral director.
Notice of Privacy Practices
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions, such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
More Restrictive State Law: Certain state laws may have more strict requirements on how we use and disclosure your PHI. If there are specific more restrictive requirements, even for some of the purposes listed above, we may not disclose your PHI without your written authorization. To the extent that there are more strict state requirements or restrictions, we will only use and disclose your PHI as permitted by those stricter requirements.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this Notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
- We will adhere to this Notice and will not use or disclose your information in a manner inconsistent with this Notice or that of any direct treatment provider that providers such a Notice on our behalf. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the Terms of this Notice
We can change the terms of this Notice, and the changes will apply to all information we have about you.
Notice of Privacy Practices
- The Notice will be promptly revised whenever there is a material change to our practices described in the Notice.
- A covered entity may not apply a revision to information received or maintained prior to the revision unless it has reserved the right to do so in its Notice.
- Unless required by law, material revisions will not be implemented prior to the effective date of the revised Notice.
- As a national medical practice with operations in numerous states, our goal is to ensure that this Notice complies with all applicable state laws as well as the Federal law. To the extend state law in those states where we operate have different or more strict laws regarding the handling of your PHI or information generally, we reserve the right to amend this Notice and adopt those required differences between what is required by applicable state laws and this Notice. The new Notice will be available upon request, in our office, and on our web site.
- The Practice’s Notice will be retained for six (6) years from its last effective date. The Practice will likewise retain acknowledgments (or adequate documentation of good faith efforts to obtain written acknowledgments from you and other patients of the Practice) for a duration of six (6) years.