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.

Introduction

Protecting the privacy of patients’ medical information is an aspect of our doctors’ Hippocratic oath and has always been an important part of our patient relationship. There are now new regulations, however, that relate to patient privacy protection. We have created this Notice of Privacy Practices in order to follow the current law and must, under the new laws, provide you with notice of our legal duties and privacy practices. We are required by law to protect the privacy of your Protected Health Information. Our office must also follow the policies that are described in the Notice.

Please read this Notice carefully as we must ask for your acknowledgement that you have read and understood it. If you have any questions, please do not hesitate to ask us. We have a Privacy Officer in our office who will answer any questions you may have about this Notice or our privacy procedures. And, you are entitled to a copy of this document and if you would like it, please ask us and we will be happy to give it to you.

Uses and Disclosures of Protected Health Information Without Patient’s Authorization

There are several circumstances in which we are allowed to use or disclose your health data without your authorization. We will disclose your protected health information for reasons related to your treatment, the payment of our health care services or our operations. We will only use and/or disclose your protected health information when the law allows us to do so. Any other use and disclosures will be made only with your authorization and, in those instances; you have the right to revoke that authorization. Any revocation will not apply to disclosures or uses already made or to disclosures or uses made in reliance on your prior authorization.

Treatment: For example, from time to time, our doctor(s) may decide that it is medically necessary to refer you to a specialist for additional care. That doctor will need your medical information in order to be able to treat you and that’s why we send out your records.

Payment: Many of our patients have medical insurance that actually pays for their medical treatment. The insurers require your medical information to know how to pay us for your care and that’s why we send out your records.

Health Care Operations: We are allowed to disclose your medical information if that is necessary for our office to function efficiently. There are also times when we may need the help of a special vendor, such as a medical billing specialist, and we would then send your records to that vendor in order for us to carry on our business.
There are certain other occasions when we are lawfully allowed to use or disclose your health information without your authorization. Those situations are more than likely what you would expect from us, but just so you are aware of them, they are:

1. When required by law: If the use or disclosure of your medical information is required of us by law, we will comply with the law but will limit our use or disclosure to the relevant requirements of the law.
    
2. For certain limited public health activities: There are certain authorities (like the Food and Drug Administration), which are authorized to collect information for the purpose of preventing or controlling disease or injury. Other agencies, such as those that obtain information regarding child abuse reports, also require information from physician offices. Still others have the right to obtain personal data to maintain vital statistics (such as birth and death records). If one of these agencies requires us to give them your health data, we will.
    
3. Necessary for the reporting of victims of abuse, neglect or domestic violence: If, in the exercise of our professional judgment, we believe disclosure is necessary to prevent serious harm, we will provide your health data to any governmental authority authorized by law to receive reports of abuse, neglect or domestic violence.
    
4. For certain health oversight activities: Sometimes we are asked to provide information to oversight agencies for activities authorized by law. These activities include, but are not limited to, criminal investigations, civil rights inquiries, inspections, audits, and work of that nature. We will cooperate with these legal authorities and provide data to them as per their statutory authorizations.
    
5. For judicial and administrative proceedings: We will also disclose your health data if we are required to do so under a court order or subpoena. If we receive this kind of a request, we will make sure that the inquiry fits the criteria we must follow for release of your data for these proceedings. Those criteria require that we only release information sought for a specific request that has a legitimate purpose. We cannot and will not produce more data than we have to and we will try to delete as much of your personal information as the law will allow.
    
6. For law enforcement purposes: The law allows us to disclose your medical information in response to legitimate lawful requests (such as from a legitimate law enforcement agency or in response to a subpoena) as follows: a) if the law requires the reporting of certain types of injuries; b) if the data is sought to help the law enforcement agencies locate a suspect, fugitive or missing person (and then we only have to provide limited descriptive data); c) if the request relates to a crime victim or some one who has died; or d) if there has been a crime on our office premises.
    
7. About decedents: If asked, we may disclose health data for the purposes of identifying someone who has died. Sometimes, funeral directors need health data in order to perform their duties. In those cases, we may also provide that information.
    
8. For cadaveric organ, eye or tissue donation purposes: The law allows us to provide health data for organ donations.
    
9. For research: If the appropriate authorities approve the privacy protection policies of a research organization, we may allow the disclosure of health information to the research organization.
    
10. To avert a serious threat to health or safety: We may also choose to report health data if we believe that is necessary to diminish a threat to anyone’s health or safety.
     
11. For specialized government functions: There are certain instances involving the government wherein we will provide your health data consistent to the applicable law. These involve veterans who need medical data for continued benefits or for armed services personnel who are leaving their branch of the service. We will also provide health data for national security and intelligence purposes or for protective services for the President of the United States or some foreign dignitaries.
     
12. Inmates: If a patient or other individual is an inmate or under the custody of a law enforcement official, we may disclose that person’s health information to correctional institutions or law enforcement officials if the information is necessary to allow the institution to provide that person with medical care, to protect the health or safety of that person or others, or to maintain the safety, security, and good order of the institution.
     
13. For limited purposes for worker’s compensation: We are allowed to give out your health information as authorized in order to comply with workers compensation or work-related injury laws or proceedings.
     

Patients’ Rights to Protected Health Information

1. You have the right to request that we restrict our disclosures of your medical information. You may ask that we limit the use and disclosure of your health information; we are not required to accept your request. IF we do agree, however, we will do as you wish except in an emergency. You must submit your request to us in writing (to the person at the bottom of this Notice) and tell us: a) what information you want us to limit b) how you want us to limit that data and c) to whom we are to limit the access to this data. You may also ask that we restrict the disclosure of your health information to only certain people.
    
2. You have the right to receive confidential communication by alternate means or at alternate locations. You have the right to request that we communicate with you about your health and related issues by alternative means or at an alternative location. For example, you may request that we contact you at work rather than at home. Please make that request in writing to our Privacy Officer at the address at the bottom of this Notice. We will agree, so long as your request is reasonable, but you must tell us how to communicate with you and you must give us a complete address or contact information.
    
3. You have the right to request access to your medical information maintained in the medical or billing records (or any of the records that we rely upon for decisions about your medical treatment) except for a) psychotherapy notes; b) information that we gather in preparation of an administrative action or proceeding; c) data that is subject to certain provisions of the Clinical Laboratory Improvements Act.
   We may deny your request (in writing) under certain limited circumstances and there are some situations in which you may appeal our decision to deny your request. Generally, if we agree to provide you with a copy of your records, we will do so within 15 business days after you ask for it, so long as your chart is in our office. We will charge you a reasonable, cost-based fee for the records.
    
4. You have the right to ask us to amend your medical information. We have the right to deny that request if you ask about medical information that a) was not created by any of our doctors; b) is not part of the medical or billing records (or any of the records that we rely upon for decisions about your medical treatment); c) is not part of the records you may access; or d) is accurate and complete.
   We may ask that you tell us, in writing, why you want us to amend your medical information. Generally, we must act upon your request within 60 days after receipt of your request. If we agree to your request, we must make the appropriate amendment and follow the law regarding how and whom we inform about this amendment. If we do not agree, then we will notify you in writing of our reasons. You then have additional rights, including the right to submit a written statement of disagreement.
    
5. You have the right to know how and to whom we’ve used or disclosed any of your medical information that identifies you. We are required to give you that data except for any use or disclosure: a) for treatment, payment and/or health care operations; b) made with your authorization; c) that we make to you; d) made to correctional institutions or law enforcement officials; or e) made before 14 April 2003. We will provide this data to you (generally, within 60 days) at no charge once each year, but after that, we will require that you pay a reasonable fee-based charge for the information.

How We Communicate with You

We believe that it is important for you to have access to extremely important medical information as soon as it is available. For that reason, we may leave a message for you on your answering machine and ask that you call us back to discuss this matter. Our doctor(s) sometimes need to be able to communicate quickly about your health information, too. For example, if you have a medical emergency, our doctor(s) may get a page and will return that call on a cell phone. These days, conversations on cell phones are not completely secure, but they are often the fastest method of communication.

We also understand that with all that you do in your life, you may not remember to call us for your next visit. For that reason, we may send you a reminder of your next appointment with our doctor(s) by telephone, mail, or both. From time to time, we may also contact you to let you know of health services we have developed in our office.

If You Want to File a Complaint about any Violation of our Privacy Practices

If you believe that we have somehow violated your privacy rights, please contact our Chief Privacy Officer at the address at the bottom of our Notice. We cannot and will not retaliate against you if you file a complaint. You also have the right to file a complaint with the Secretary of Health and Human Services.

 Our Privacy Officer

If you have any questions or comments about this Notice, please contact our Chief Privacy Officer at this address:

 

This Notice was revised as of 9 May 2005. The original Notice was effective as of 14 April 2003. From time to time, we may revise our Notice. If we do, we will post the most current version in our office and on our website at www.gonzaba.com. You may ask for a copy of the Notice at any time.