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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. Uses and Disclosures Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing your medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health care professionals who may provide treatment or who may be consulted by staff members. Payment. Your health information may be used to seek payment from your health plan or other sources of medical coverage, or any other organization that you may use to pay the Hand Center of Western Connecticut for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of the Hand Center of Western Connecticut. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Law enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting. Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department. Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your health information you may submit a written revocation of the authorization. Please note that your decision to revoke the original authorization will not affect or undo any use or disclosure of your health information that occurred before you notified us of your decision. Additional Uses of Information Appointment reminders. Your health information will be used by our staff to communicate appointment reminders. Appointment confirmation is generally via a telephone call to your place of residence, but may be made via the mail. If you do not wish to be contacted at home, please complete a Request for Confidential Communication of Protected Health Information form available at the reception desk. Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may find of interest. We may also send you information describing other health-related goods and services that we believe may interest you. Individual Rights You have certain rights under the federal privacy standards. These include: • the right to request restrictions on the use and disclosure of your protected health information (as indicated on your Consent to Use and Disclosure of Protected Health Information form); • the right to receive confidential communications concerning your medical condition and treatment (if applicable, please complete a Request for Confidential Communication of Protected Health Information form); • the right to inspect and/or request a copy of your protected health information in accordance with 45 CFR 164.524(b)(1). Requests for access to protected health information must be made in writing using a Request to Inspect or Copy Protected Health Information form. You are entitled to a response within thirty (30) days of your request. If applicable, 45 CFR 164.524(c)(4) permits a provider to charge a cost-based fee for copies of requested protected health information not to exceed sixty-five ($.65) cents per page, and if applicable, the cost of postage as requested by the patient. A patient’s request to inspect or copy protected health information may be denied if it involves psychotherapy notes, information used in legal proceedings, or information that cannot be disclosed under the Clinical Laboratory Improvement Amendments (CLIA) per 45 CFR 164.524(a)(2), or a licensed health professional determines that access to the information may result in harm to the patient or others per 45 CFR 164.524(a)(3). You may request an appeal by completing a Review of Denial to Permit Inspection or Copying of Protected Health Information form; • the right to amend or submit corrections to your protected health information in accordance with 45 CFR 164.526(b). Requests for amendments must be made in writing using a Request to Amend Protected Health Information form. You are entitled to a response within sixty (60) days of your request. A patient’s request to amend protected health information may be denied if the requested amendment is for information not created by the Hand Center of Western Connecticut, the information is accurate and complete as entered, or the information does not exist in the specified record. You may submit a statement of disagreement if notified that a request for amendment of protected health information was denied; the Privacy Officer will review the statement of disagreement and determine whether a formal rebuttal or response is required per 45 CFR 164.526(d)(4) and (5). • the right to receive an accounting of how and whom your protected health information has been disclosed by completing a Request for Accounting of Protected Health Information Disclosures form. You are entitled to a response within sixty (60) days of your request. In accordance with 45 CFR 164.528(c), the patient will not be charged for the first requested accounting during any twelve (12) month period; second and subsequent requests during any twelve (12) month period will incur a cost of ten ($10.00) dollars per request payable in advance. • the right to receive a printed copy of this notice. Hand Center of Western Connecticut Duties We are required by law to maintain the privacy of your protected health information and provide you with this notice of privacy practices. We are required to abide by the privacy policies and practices that are outlined in this notice. In accordance with 45 CFR 160.530(i)(1), the Hand Center of Western Connecticut developed a complete Patient Privacy Manual and implemented policies and procedures to ensure the privacy of your protected health information which meets all federal privacy standards. In accordance with 45 CFR 164.530(b)(1), all employees and staff members of the Hand Center of Western Connecticut receive orientation and training regarding use and disclosure of your protected health information; at all times, the Hand Center of Western Connecticut will limit use and disclosure of your protected health information to the minimum necessary for a specific purpose. If you do not understand all or part of this Notice of Privacy Practices, please notify the receptionist or Privacy Officer. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for the revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain. Consent to Use and Disclosure of Protected Health Information Signature Requirements All patients are required to sign the Consent to Use and Disclosure of Protected Health Information form prior to obtaining any medical service or treatment at the Hand Center of Western Connecticut in accordance with 45 CFR 164.506(a). Federal law prevents a provider from using the patient’s information for the purposes of treatment or payment if consent is not given. You may request restrictions on the use and disclosure of your protected health information, subject to review by the Privacy Officer, or revoke your consent at any time by completing a Revocation of Consent to Use and Disclosure of Protected Health Information form. PLEASE NOTE: In accordance with 45 CFR 164.506(b), the Hand Center of Western Connecticut reserves the right to deny non-emergent medical care and treatment to a patient who refuses to sign a Consent to Use and Disclosure of Protected Health Information form. Authorization of Use or Disclosure of Protected Health Information Signature Requirements Consent to Use and Disclosure of Protected Health Information is specific to treatment, payment, and day-to-day health care operations; it is a general consent for that purpose only. Any other use or disclosure of your information requires your specific written permission, and completion of an Authorization of Use and Disclosure of Protected Health Information form. This authorization specifies exactly what information you wish released, who will receive this information, and the expiration date of your authorization. You also have the right to terminate or revoke your authorization at any time by completing a Revocation of Authorization for Use and Disclosure of Protected Health Information form. Requests from any source, except those mandated by federal or state law, for protected health information not related to treatment, payment, or day-to-day health care operations will not be honored without completion of an Authorization of Use and Disclosure of Protected Health Information form. Requests to Inspect Protected Health Information As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a Request to Inspect or Copy Protected Health Information form from the receptionist or the Privacy Officer. Complaints If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Privacy Officer If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concerns to the same address. You will not be penalized or otherwise retaliated against for filing a complaint. Contact Person The name and address of the person you can contact for further information concerning our privacy practices is: Privacy Officer Effective Date This notice is effective on or after April 14, 2003 |
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| © 2008 The Hand Center of Western Connecticut • 35 Tamarack Ave • Danbury, CT 06811 Phone (203)792-4263 • Fax (203)792-1365 • email: handcenter@hand-center.com |