NOTICE OF PRIVACY PRACTICES
DAVID K. EMMEL, MD
Effective Date of this Notice: April 14, 2003, revised effective September 23, 2013
Privacy Officer Contact name:
Jessica Scougall, 1260 Silas Deane Highway Ste #110 Wethersfield, CT 06109
Privacy Contact Officer Telephone Number:
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.
We understand that your medical/health information is personal and private. In order to provide you with quality care and to ensure compliance with certain legal requirements, we create a record of the care and services you receive in our office(s). We respect the privacy and confidentiality of medical/health information about you and that can be identified with you. This is called “protected health information”. Your protected health information is contained in the medical and billing records maintained by our practice. It includes demographic information and information that relates to your present, past or future physical or mental health and related health care services.
This Notice of Privacy Practices (“Notice”) describes the ways in which we may use and disclose your protected health information. It also describes your rights and our legal obligations with respect to your protected health information.
This Notice applies to uses and disclosures we may make of all your protected health information, whether created by us in our practice or received by us from another health care provider.
A. OUR LEGAL DUTY TO PROTECT YOUR HEALTH INFORMATION
Federal and State laws require us to:
§ Ensure the privacy of your protected health information, which we have either created in our practice or received from another health care provider, whether it is about your past, present, or future health care condition;
§ Maintain the privacy of your protected health information regarding payment for your health care;
§ Explain the manner in which we may use and disclose your protected health information; Abide by the terms of this Notice, as currently in effect; and
§ Obtain your written authorization to use or disclose your protected health information for reasons other than those listed below and permitted by law.
We reserve the right to amend this Notice at any time in the future, and make the new provisions effective for all protected health we maintain, regardless of when it was created or received. If the Notice is amended, we will:
§ Post the revised Notice, with the new effective date, in our office(s);
§ If we have a website, post the revised Notice on our website; and
§ Make copies of the revised Notice available to you upon request.
In the process of using or disclosing your protected health information for an authorized use, we may make incidental disclosures. We will take reasonable steps to limit incidental disclosures.
B. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION TO PROVIDE YOU WITH TREATMENT, TO OBTAIN PAYMENT FOR SERVICES RENDERED To YOU, AND FOR HEALTH CARE OPERATIONS.
1. For treatment:
We may use and disclose your protected health information to provide you with medical treatment and services, and to coordinate or manage your health care and related services. We may disclose your protected health information to our doctors and nurses, as well as to any otherparty involved in your care, either within our practice or to an outside health care provider. We may also disclose your protected health information to providers or facilities who may be involved in your care after you leave our facility or our care.
A practice-specific example: Our health care providers may disclose information about your health condition to a physician to whom you have been referred, a pharmacist who needs the information to dispense your prescription, or a laboratory that requires it to perform testing.
We may use and disclose your protected health information to bill and receive payment for the treatment and services we provide. We may disclose your protected health information to an insurance company or managed care company, Medicare, Medicaid, or any other third partypayor. We may also provide protected health information to collection departments, consumer reporting agencies or any other health care provider who requests information necessary for them to collect payment.
A practice-specific example: We may inform your insurance company about a treatment that we intend to provide so that we can obtain the appropriate approvals and/or to confirm coverage for your treatment.
We may use and disclose your protected health information as necessary for us to operate our medical practice. We may use and disclose your protected health information for internal operations, such as general administrative activities and quality assurance programs.
For example, we may use and disclose your protected health information:
§ To review and improve the quality of care you receive;
§ To train and educate doctors, nurses, students, volunteers or other medical staff;
§ To plan for services, such as when we assess certain services that we may want to offer in the future;
§ To evaluate the performance of our employees;
§ To our lawyers, consultants, accountants, and other business associates;
§ To compare your information with that of several other patients to determine if we should offer new services or if new treatments were effective;
§ To identify groups of patients who have similar health problems (“population management”) to give them information about treatment alternatives, programs, or new procedures;
§ To organizations that assess the quality of care we provide to our patients (such as government agencies or accrediting bodies);
§ To organizations that evaluate, certify or license health care providers, staff or facilities in a particular specialty;
§ To assist others who may be reviewing our activities, such as accountants, lawyers, consultants, risk managers, to assist us in complying with state and federal laws;
§ If we are in the process of selling our business or merging with other health care entities, or giving control to someone else;
§ For procedures involving health care fraud and abuse detection and compliance; and
§ To develop internal protocols.
Practice-specific example: We may disclose information as it relates to health care o operations to accountants who are auditing our billing records.
C. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION IN LIMITED SITUATIONS.
The following are situations in which we may use or disclose your protected health information without your written authorization or an opportunity for you to agree or object, as described below.
We may disclose your protected health information when required to do so by federal, state or local law or other judicial or administrative proceedings.
We may use or disclose protected health information as necessary in emergency treatment situations.
We may disclose your protected health information for public health activities. For example, we may disclose protected health information about you if you have been exposed to a communicable disease or may otherwise be at risk of spreading a disease. Other examples may include reports about injuries or disability, reports of births and deaths, reports of child abuse and/or neglect, and reports regarding the recall of products.
Unless you object, we may use and disclose certain limited information about you on our sign-in sheet while you are in our office(s). This information may include your name, but will not include information about your condition. We will also call your name to notify you that the provider is ready to see you or that we need to discuss something with you.
Unless you object, we may disclose protected health information about you to a family member, relative, close personal friend or any other person you identify, including clergy, who is involved in your care. These disclosures are limited to information relevant to the person’s involvement in your care or in payment for your care.
Unless you object, we may disclose protected health information about you to an organization assisting in disaster relief efforts. Even if you object, we may still share information about you if necessary to respond to emergency circumstances.
When authorized by law, or if you agree to the report, and if we believe that you have been a victim of abuse or neglect, we may use and disclose your protected health information to notify a government authority.
When authorized by law, we may disclose your protected health information to a health oversight agency for activities, such as audits, investigations, inspections, licensure actions or other legal proceedings. A health oversight agency is a state or federal agency that oversees the health care system.
We may disclose your protected health information in response to a court or an administrative order. In certain circumstances, we also may disclose protected health information in response to a subpoena, a discovery request, or any other lawful process by another party involved in the action. We will make a reasonable effort to inform you about the request.
We may disclose your protected health information for certain law enforcement purposes, including, but not limited to:
§ Reporting certain types of wounds and/or other physical injuries (i.e. gunshot wounds); Reports required by law;
§ Reporting emergencies or suspicious deaths;
§ Complying with a court order, warrant, subpoena (in certain circumstances), or other legal process;
§ Identifying or locating a suspect or missing person, material witness or fugitive;
§ Answering certain requests for information concerning crimes, about the victim of crimes;
§ Reporting and/or answering requests about a death we believe may be the result of a crime;
§ Reporting criminal conduct that took place on our premises; and
§ In emergency situations to report a crime, the location of the crime or victim or the identity, description and/or location of a person involved in the crime.
We may disclose your protected health information to a coroner, medical examiner or funeral director. We may disclose information about deceased patients to funeral directors if necessary to allow them to carry out their duties. We may disclose protected health information about you to a coroner or medical examiner for the purposes of identifying you should you die.
If you are an organ donor, we may disclose your protected health information to an organization involved in the donation of organs and tissue to enable them to carry out their lawful duties.
In some situations, your protected health information may be used for research purposes, provided that the privacy and safety aspects of the research have been reviewed and approved by an institutional review board or a privacy board. The board must have established procedures to ensure that your protected health information remains confidential.
We may use or disclose your protected health information if we believe it is necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. We may only make the disclosure to a person or entity that would be able to help lessen or prevent the threatened harm.
If you are a member of the armed forces, we may use and disclose your protected health information as required by military command authorities. We may also disclose your protected health information to the appropriate foreign military authority if you are a member of a foreign military.
We may disclose protected health information to authorized federal officials conducting national security, counterintelligence, and intelligence activities authorized by law.
We may disclose your protected health information to authorized federal officials, as needed, to provide protection to the President of the United States, other authorized persons, foreign heads of states or to conduct certain special investigations.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your protected health information to the correctional institution or law enforcement official for the following purposes:
§ To enable the correctional institution or law enforcement official to provide you with necessary health care services;
§ To protect your own health and safety;
§ To protect the health and safety of others; and/or
§ For the safety and security of the correctional institution.
We may use or disclose your protected health information to comply with laws and regulations relating to workers’ compensation or similar programs established by law that provide benefits for work-related injuries and/or illnesses.
If we engage in any fundraising activities allowed by HIPAA, we may use limited protected health information such as your name, address and phone number, age, gender, date of birth, your treating physician, outcome information your health insurance status, and the dates you received treatment or services, to contact you in an effort to raise money for a program developed by our practice. We may also disclose contact information for fundraising purposes to a foundation related to our organization.
You have a right to instruct us not to contact you about fundraising. If you do not want to be contacted, you should notify us in writing by contacting the please contact the Privacy Contact Office at the telephone number listed on the first page of this Notice who will explain whether we do any fundraising, and if so, how you may Opt Out of fundraising communications.
We may use or disclose protected health information to remind you about:
§ appointments in our organization; and
§ appointments that we have scheduled for you with other health care organizations.
Please note that we will may use the contact information that you have provided to us to mail or call with appointment reminders or notifications of missed appointments.
We may disclose your protected health information to our business associates under Business Associate Agreements. Business associates may include:
§ Answering Services;
§ Transcription Services;
§ Accounting Services;
§ Attorney/Legal Services.
D. YOUR AUTHORIZATION IS REQUIRED FOR ALL OTHER USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION.
Except for those circumstances listed above, we will use and disclose your protected health information only with your written authorization. You may revoke your authorization, in writing, at any time. If you revoke an authorization, we will no longer use or disclose your protected health information for the purposes covered by that authorization, except where we have already relied on the authorization.
Please note that our use or disclosure of your protected health information relating to: psychotherapy notes (if we have such notes), for marketing purposes, and for the any sale of protected health information generally require your authorization.
E. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION.
You have the following rights regarding your protected health information that we maintain:
Except under limited circumstances, and upon written request, you have the right to inspect and obtain a copy of your protected health information. Your protected health information is contained in our medical and billing records or any other record used by us to make decisions about your care.
Under current state law, we may charge you no more than 0.65 cents per page, plus firstclass postage, if we make a copy of your medical record. (There are some circumstances under which we are not permitted to charge you for the record, but in most cases we may charge.) We may also charge you a reasonable fee for copying x-rays and furnishing tissue slides or blocks.
To inspect and request a copy of your protected health information, you should submit your written request to us.
We must respond to your request within 30 days, by either supplying the records or sending a written notification of denial. We may deny your request to inspect or receive copies of your protected health information in the following limited circumstances:
§ The information was compiled exclusively in connection with a criminal, civil or administrative proceeding;
§ The disclosure to the patient is prohibited by the Clinical Laboratory Improvement Act (42 U.S.C. §263a);
§ You are a correctional institution inmate and the correctional administrators have provided reasons for denying access;
§ The information is for a research study not yet complete; The Privacy Act (5 U.S.C. §552a) prohibits access;
§ The information was obtained by a person other than a health care provider upon our promise to keep the information confidential, and access would reveal the informant’s identity;
§ We determine access is likely to endanger the life or safety of the patient or others;
§ The information contains information about another person and we determine that access is likely to cause substantial harm to that person;
§ The request for access is made by the patient’s personal representative and we believe access is likely to cause substantial harm to the patient or others.
If you are denied access to your protected health information, in some cases you will have the right to request a review of this denial. The review will be performed by a licensed health care professional designated by us, who did not participate in the original decision to denyaccess.
You have the right to request a restriction on the way we use or disclose your protected health information for treatment, payment or health care operations. You also have the right to request restrictions on the protected health information that we disclose about you to a family member, friend or other person involved in your care or the payment of your care.
If you wish to request such a restriction, you should submit your written request to us. You must tell us what information you want restricted, to whom you want the information restricted, and whether you want to limit our use, disclosure or both.
Generally, we are not required to agree to such a restriction. If we do agree to the restriction, we will honor that restriction except as needed to provide you with emergency treatment.
We are required to honor your requested restriction that we withhold protected health information from your insurance plan, subject to you paying for the services you do not wish disclosed, and other specific details. If you wish to request such a restriction, please let us know immediately. We will provide you with additional details on how to obtain this restriction. Be advised, Medicaid may not allow you to make this request.
You have the right to request that we communicate with you concerning your health matters in a certain manner or at a certain location. For example, you can request that we contact you only at a certain phone number or a specific address.
You should submit your written request for confidential communications to us. You must tell us how and where you want to be contacted.
We will accommodate your reasonable requests, but may deny the request if you are unable to provide us with appropriate methods of contacting you.
You have the right to request that we amend medical or billing records, or other protected health information maintained by us, for as long as the information is kept by us. Your request must be made in writing and must explain the reasons for the requested amendment.
We may deny your request for amendment if the information:
§ was not created by us (unless you prove the creator of the information is no longer available to amend the record);
§ is not part of the records maintained by us; in our opinion, is accurate and complete;
§ is information to which you do not have a right of access.
We must respond to your request within 60 days of receiving the request. If we agree to the amendment, we will notify you and amend the relevant portions of your medical record. We will also make a reasonable effort to inform business associates and other individuals known to us, or identified by you, as having the protected health information being amended.
If we deny your request for amendment, we will give you a written denial notice, including the reasons for the denial and explain to you that you have the right to submit a written statement disagreeing with the denial. Your statement of disagreement will be attached to your medical record. If you should submit a statement of disagreement, we have the right to insert a rebuttal statement into the medical record. We will provide you with a copy of the rebuttal statement. If you do not wish to submit a statement of disagreement, you may request that a copy of the amendment request and a copy of our denial be included with all future disclosures.
Should we deny your request for an amendment, you have the right to pursue a complaint process by contacting our Privacy Contact Office, or you may contact the Secretary of Health and Human Services to lodge your complaint.
If you wish to request an amendment, you should submit the request to us in writing.
You have the right to request an accounting of certain disclosures of your protected health information made after April 14, 2003. You may request an accounting of disclosures made up to six (6) years before the date of your request, beginning with records created on or after April 14, 2003. An accounting is a listing of disclosures made by us or by others on our behalf, but does not include:
§ disclosures made for treatment, payment and health care operations;
§ disclosures made directly to you, that you authorized, or those which are made to individuals involved in your care;
§ disclosure made to correctional institutions or law enforcement official about an inmate in custody;
§ disclosure made for national security or intelligence purposes; disclosure of a limited data set; or an incidental disclosure.
You must submit your request for an accounting of disclosures to us in writing. You must state the time period for which you would like the accounting. We must respond to you 60 days after receipt of your request. The accounting will include the disclosure o date, the name, address (if known) of the person or entity that received the information, a brief description of the information disclosed, and a brief statement of the purpose of the disclosure. If you request a listing of disclosures more than once within a 12-month period, we will charge you a reasonable fee for the accounting. The first accounting, within a 12- month period, is provided to you at no charge.
You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting our office in writing or by phone. In addition, you may obtain a copy of this Notice on our website, Pediatricsplus.net (in development).
7. Right to Be Notified of a Breach of Unsecured Protected Health Information You have the right to be notified in the event there is a breach of your unsecured protected health information. While we never expect this to happen, if it does, we will contact you (usually by mailing a letter, but we might also call you) to explain what happened, and provide you with additional details and we will let you know that who you can call at our office for more information.
F. SPECIAL RULES REGARDING THE DISCLOSURE OF MENTAL HEALTH CONDITIONS, SUBSTANCE ABUSE, AND HIV-RELATED INFORMATION.
For uses and disclosures of your protected health information related to care for mental health conditions, substance abuse, or HIV-related information, special restrictions may apply. For example, we generally may not disclose this specially protected information in response to a subpoena, warrant or other legal process unless you sign a special authorization or if a court orders the disclosure.
If needed for your diagnosis or treatment in a mental health program, mental health information may be disclosed as needed between your treatment team members, and very limited information may be disclosed for payment purposes. Otherwise mental health information may not be disclosed without your authorization, except as specifically permitted by state or federal law.
HIV related information will not be disclosed, except under limited circumstances set forth under state or federal law, without your specific written authorization.
If you are treated in a substance abuse program, information which could identify you as alcohol or drug-dependant will not be disclosed without your specific authorization except for purposes of treatment or payment or when specifically required or allowed under state or federal law.
A special authorization is required for the disclosure of psychotherapy notes, and special rules may apply which limit the information which is disclosed.
If you believe that your privacy rights have been violated, you may file a complaint in writing with us or with the federal government.
1. To file a complaint with the federal government, you may contact:
If you are in Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont: Peter Chan, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services Government Center
JøF.Kennedy Federal Building – Room 1875 Boston, MA 02203
Voice phone (800) 368-1019 or TDD (800) 537-7697
FAX (617) 565-3809
If you are in New Jersey, New York, Puerto Rico, or the Virgin Islands: Linda Colon, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services Jacob Javits Federal Building
26 Federal Plaza – Suite 3312 New York, NY 10278
Voice Phone (800) 368-1019 or TDD (800) 537-7697
FAX (212) 264-3039
You may file a complaint through the OCR Complaint Portal at: https://occportal.hhs.gov/ocr/cp/complaint_frontpage.jsf
2. To request additional information, to request that we respond to questions, or to file a complaint, you should contact the Privacy Contact Office listed on page one.
3. You will not be retaliated against for filing a complaint.