Effective Date: July 1, 2010
PLEASE READ CAREFULLY. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. OnTheWall™ is a trademark of Segmedica, Inc. If you have any questions about this Notice please contact: Privacy Officer at the office of Segmedica, 935 Sheridan Drive, Tonawanda, New York 14150, (716) 754-8744
This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information, for purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information. This Notice of Privacy Practices has been prepared consistent with the federal regulation known as “The HIPAA Privacy Rule.” Segmedica, Inc. is not a covered entity and does not engage in treatment, payment or health care operations.
A. Protected Health Information – “Protected Health Information” (PHI) 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 conditions related to health care services, and payments for those services. We are required to maintain the confidentiality of any health information we receive from a covered entity that identifies you.
B. Revisions and Amendments – We will abide by the terms of this Notice while it is in effect. The terms of this Notice apply to all records containing your Protected Health Information that are created or retained by Segmedica. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that we have created or maintained in the past and for those we may create or maintain in the future.
C. Availability of our Notice- We will maintain this Notice of the privacy practices that we maintain in our office concerning your Protected Health Information. You are entitled to a copy of the most current Notice at any time. If you do not already have a copy, we will provide you with a written copy of our Notice of Privacy Practices upon request. You may obtain any revised Notice of Privacy Practices by calling our office at (716) 754-8744. You can request that a written copy of our revised Notice to be sent to you in the mail.
III. USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
Required Disclosures- We are required to disclose your Protected Health Information to you, upon request, and to the Secretary of Department of Heath and Human Services (DHHS) to investigate or determine compliance with the privacy rules that direct the terms of this Notice.
Treatment, Payment and Healthcare Operations- We do not engage in treatment, payment or healthcare operations for you or on behalf of any treating medical professional.
Business Associates- The office of Segmedica has third-party “business associates” that perform various activities and to whom we may disclose your Protected Health Information. In such event, the third party will sign a written agreement that will require it to protect the privacy of your Protected Health Information.
Your Family and Friends- Unless you object, we may disclose your Protected Health Information to a member of your family, a relative, personal representative, another person responsible for your care, or any other person you identify as a designated contact person. If you are unable to agree or object to such disclosure, we may disclose such information as necessary to the delivery of our services to you. For example, we may disclose to your representative such portion of your information as is directly related to that person’s involvement in your health care, such as your location, general condition or death.
Communication Barrier- We may use or disclose your Protected Health Information if we have attempted but are unable to successfully obtain your consent due to a substantial communication barrier if we determine, using our professional judgment, that that you do consent to the use or disclosure.
In the limited circumstances listed below, Segmedica is permitted to further use and disclose your Protected Health Information:
1. Emergencies- We may use or disclose your Protected Health Information to an authorized public or private entity to assist in disaster relief efforts, or in an emergency treatment situation. In a life-threatening emergency, your health care providers are permitted to use or disclose Protected Health Information to treat you, without a signed authorization or consent. If this happens, we shall try to obtain your consent as soon as is reasonably practicable after the delivery of services.
2. Required by Law- We may use or disclose your Protected Health Information to the extent that it is required of us by law, and we will do so in the manner and scope required by the law. You will be notified, as required by law, of any such use or disclosure.
3. Public Health Purposes- We may use or 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. Such purpose may include controlling disease, injury or disability. If directed to do so by a public health authority, we may also use or disclose your Protected Health Information to a foreign government agency with which it is working in collaboration.
4. Victims of Domestic Violence, or Other Forms of Abuse or Neglect- We may use or disclose your Protected Health Information to a governmental entity or public health authority that is authorized by law to receive reports of child abuse or neglect, or if we believe you have been the victim of domestic violence or abuse or neglect. In this case, disclosure will be made in accordance with such entity’s or authority’s requirements.
5. Required by Health Oversight Agencies- We may use or disclose your Protected Health Information to a health oversight agency for activities authorized by law such as audits, investigations and inspections. Oversight agencies that may seek this information include government agencies that oversee the health care system, government benefits programs, other government regulatory programs and civil rights laws.
6. Judicial Proceedings- We may use or disclose your Protected Health Information in the course of any legal, judicial or administrative proceeding, and when ordered or authorized to do so, in response to an order, subpoena, discovery request or other lawful process of a court or administrative tribunal.
7. Law enforcement- We may use or disclose your Protected Health Information for law enforcement purposes, or when asked to do so by a law enforcement official, so long as applicable legal requirements are met. These purposes include: legal processes and as otherwise required by law, in response to a legal process such as subpoena, court order, summons or warrant, limited information requests for identification and location of a suspect, material witness fugitive or missing person, pertaining to victims of a crime, suspicion that death has occurred as a result of criminal conduct, in the event that a crime occurs on the premises of the practice, and for information purposes to report a perpetrator or a victim in an emergency not on the premises when it is likely that a crime has occurred.
8. Medical Examiners, Funeral Directors- We may use or disclose your 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, or to a funeral director to perform their jobs.
9. Organ and Tissue Donation- We may use or disclose your Protected Health Information to organizations that conduct organ and tissue donations and transplantation, if you are a registered donor.
10. Research- We may use or disclose your Protected Health Information to medical researchers in certain limited circumstances, when release of the information was approved by an institutional review board that has reviewed their research practices, and determined that they have established protocols to ensure the privacy of your Protected Health Information.
11. Health and Safety- We may use or disclose your Protected Health Information when needed to prevent or lesson a serious and imminent threat to your health and safety or the health and safety of other persons or the public.
12. Military- We may use or disclose your Protected Health Information to if you are or were a member of the U.S. armed forces or foreign military and we are required to do so by military command authorities, for the purposes of determining eligibility for benefits through the Department of Veterans Affairs, or to a foreign military authority if you are or were a member of a foreign military service.
13. National Security- We may use or disclose your Protected Health Information to federal officials for national intelligence and security, to protect the U.S. President or other officials, and investigations.
14. Worker’s Compensation- We may use or disclose your Protected Health Information to comply with worker’s compensation laws and similar programs.
15. Inmates- We may use or disclose your Protected Health Information to corrections institutions or law enforcement officials if you are an inmate in a correctional facility or under the custody of a law enforcement official, and we obtained Protected Health Information in the course of interacting with you, if the disclosure is for the institution to provide care to you, for the safety and security of the institution and/or to protect your health or the health and safety of others.
16. Required Uses and Disclosures- We may use or disclose your Protected Health Information when required to do so by federal, state or local law, or by the federal U.S. Secretary of the Department of Health and Human Services to investigate or determine compliance with their requirements.
17. Special Treatment of Confidential Health Information- Certain health information about you may be treated differently and with an even higher level of confidentiality due to its sensitive nature as defined in state and federal law. This includes HIV-Related Information, certain substance abuse, drug or alcohol dependency treatment information, and certain mental health information.
IV. YOUR RIGHTS AND DESCRIPTION OF HOW YOU MAY EXERCISE THE RIGHTS
You have the following rights regarding your Protected Health Information. For each of these rights, you must submit your requests to our Privacy Officer in writing. Your request must be clear and concise and describe your concern in as much detail as possible. We have Request forms that you may, but are not required to use. Our Privacy Officer can send you a copy or help you understand what the Requests must contain. We encourage you to speak with our Privacy Officer both before and after you provide your request in writing, to confirm whether or not we received, understood, and/or agree to it.
A. Right to Request Restrictions- You have the right to request that we place additional restrictions or not use or disclose any part of your Protected Health Information for the purposes we intend. If you self-paid for the services that are the subject of this request to limit or restrict, we must honor it in full. We are not required by HIPAA to agree with your request for restriction in every other case. However, if we do agree, we must abide by your request and we are not permitted to make the restricted use or disclosure of your Protected Health Information unless we are required to do so or unless it is an emergency. You may choose certain individuals or entities on whom you want additional restrictions placed. Your request must explain whether you are restricting use or disclosure or both, and to whom you want the restriction to apply. We will indicate our response in writing.
B. Right to Receive Confidential Communications- You have the right to receive confidential communications from us. You have the right to request that we communicate with you in a particular manner or at certain locations. For example, you may ask us to contact you at home rather than at work. Your request must describe how and where you would like to be contacted by us, and provide us with the alternative means by which we can communicate with you. You are not required to provide any specific reason for your request, except that it is necessary to protect you. We will accommodate all reasonable requests.
C. Right of Access to Inspect & Copy Information- You have the right to access, for the purposes of inspection and to copy, your Protected Health Information. This information is contained in a designated record set, that we keep for as long as we continue to maintain Protected Health Information. A “designated record set” includes all records kept or received about you in the course of conducting our business. You have a right to access all of this information except; psychotherapy notes, information compiled in reasonable anticipation of, or use in, a judicial proceeding, or as otherwise prohibited by law. Under special circumstances, we may not be required to agree with your request. If we object, you may have the right to a review of our decision. If we do agree to your request, we are permitted to charge a fee for the copying, mailing, labor and supplies associated with fulfilling your request. Your request must detail the information you would like to inspect and/or copy, the type of information (such as billing or delivery records) and the dates.
D. Right to Amend or Correct- You have the right to request that we amend or correct your Protected Health Information, in the event that you believe it is incomplete or incorrect. If we agree to the change, we are required to retain the amendment in your designated record set for as long as we maintain Protected Health Information. Under special circumstances, we may not be required to agree with your request, such when we did not create the information you want changed, or if we believe the information we have is accurate and complete. If we object, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement. We are then required to include your statements in your file along with ours.
E. Right to an Accounting of Disclosures- You have the right to an accounting from us of all disclosures that we have made, if any, containing your Protected Health Information. This accounting consists of a list of disclosures we have made, if any, since July 1, 2010, for purposes other than your treatment, payment and a covered entity’s healthcare operations, other than to your family, friends or other person involved in your care. There may be exceptions to this right. We may charge you a fee for the cost of copying and mailing. Your request must define a time period.
F. Right to a Paper Copy of this Notice- You have the right to a paper copy of our Notice of Privacy Practices, and to receive a copy of any future updated notices. You may ask us to give you a copy of this notice at any time, even if you have agreed to accept this notice electronically. To obtain a paper copy of this notice, please contact our Privacy Officer.
G. Right to File a Complaint- You have the right to file a complaint with us or with the Secretary of the Department of Health and Human Services, if you believe your privacy rights have been violated. To file a complaint with us, please contact our Privacy Officer. All complaints must be in writing. You will not be penalized for filing a complaint.
H. Right to Provide Authorization for Other Uses and Disclosures- You have the right to be asked before we use or disclose your Protected Health Information for any purposes. You do not have to agree with our request. If you do not agree, your information will not be used for these purposes.
I. Right to Ask Questions- Again, if you have any questions regarding this notice and our privacy policies, you are encouraged to contact our Privacy Officer at:
Privacy Officer at the office of Segmedica, 935 Sheridan Drive, Tonawanda, New York 14150
This Notice of Privacy Practices is effective July 1, 2010
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