NOTICE OF PRIVACY
OB/GYN of Fairfield County, LLC
1735 Post Road Fairfield, CT 06824
Effective: March 1, 2004
|Privacy Officer/Contact Address
Phone: Confidential Compliance
|Mary Holmes / 1735 Post Road, Fairfield, CT 06825
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This practice is committed to protecting the privacy and confidentiality of your protected health information. This Notice describes your rights and certain obligations we have regarding our privacy practices and the use and disclosure of your protected health information. “Protected health information” 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 condition and related health care services.
This Notice describes the privacy practices of OB/GYN of Fairfield County, LLC. This entity, all sites and locations of this entity, follow the terms of this Notice. In addition, this entity, sites and locations may share protected health information with each other for treatment, payment or health care operation purposes described herein.
This practice is required by law to protect the privacy of your protected health information and to provide you with and to abide by the terms of this Notice as it may be updated from time to time. If you have any questions about this Notice, please call the contact listed above.
USES AND DISCLOSURE OF PROTECTED HEALTH INFORMATION WE MAY MAKE WITHOUT YOUR WRITTEN AUTHORIZATION
The following categories describe different ways that we use and disclose protected health information. While not every use or disclosure in a category will be listed, all of the ways we are permitted to use and disclose information will fall within one of the categories.
The law permits us to use and disclose your protected health information for purposes of healthcare treatment, payment and healthcare operations as described below.
Ø Treatment We may use protected health information about you to provide you with medical treatment or services and to coordinate and manage your care and any related services. Protected health information about you may be disclosed to hospitals, nursing facilities, doctors, nurses, technicians, medical students and other personnel who are involved in your care. We may disclose information to people outside our practice who may be involved in your care, such as designated family members. We may also disclose your protected health information to providers or facilities that may be involved in your care after you leave our office or our care. This would include, for example, when your physician consults with a specialist or your primary care physician, regarding your condition or coordinates services you may need, such as lab work and x-rays.
Ø Payment We may use and disclose protected health information about you so that we can bill and receive payment for the treatment and services you receive from us. For billing and payment purposes we may disclose your protected health information to an insurance company, Medicare, Medicaid or any other third party payer. We may also disclose information to other healthcare providers to assist them in obtaining payment for services they have provided to you. We may give your health plan information about you before it pays for the health care services we recommend for you. Such as: making a determination of eligibility or coverage for insurance benefits, preauthorization for services. As required by your health plan, we may disclose information about you for reviewing services provided to you for medical necessity and undertaking utilization review activities.
Ø Health Care Operations We may use and disclose protected health information about you in a number of different ways related to how we run our practice. These uses and disclosures are necessary to run our practice and ensure that all of our patients receive quality care. For example, we may use protected health information to review our treatment and services and to evaluate the performance of our providers in caring for you. We may also disclose information to doctors, nurses, technicians, and medical students for review and learning purposes. Information may also be disclosed for activities relating to protocol development, case management and care coordination, reviewing qualifications of physicians, clinical trials and conducting or arranging for other business operations of our practice. We may disclose information as it relates to healthcare operations when we leave messages on your answering machine or at your place of employment when the contact phone number is given us as a method of reaching you. We may call you by name when you are in our practice. We may disclose information to computer technology and support technicians. If we share office space with other healthcare providers, we may disclose information when we call your name or store your information at a shared location.
We will disclose your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services, answering services, attorney/legal services, consultants or accountants, risk managers) for this practice. Whenever an arrangement with a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
Other Uses and Disclosures We May Make Without your Written Authorization:
Under the law, we may use and disclose your protected health information for which you do not have to give authorization or otherwise have the opportunity to agree or object. “Use” refers to our internal use of your protected health information. “Disclosure” refers to the provision of information by us to parties outside of our practice. We may make the following uses and disclosures of your protected health information without a written authorization from you in situations such as:
Ø Appointment Reminders/Sign in Sheets We may use and disclose protected health information to contact you as a reminder that you have an appointment or to see your physician or are due to schedule follow up appointments. We may ask you to sign in when you arrive at our office. We may call your name when we are ready to see you. We may display photo images, which you have sent us, such as birth announcements, greeting cards, any of which may have your name or the names and images of other members of your family.
Ø Marketing/Health-Related Benefits and Services We may use and disclose protected health information to tell you about health-related benefits and services to your treatment, case management or care coordination or recommend possible treatment options or alternatives that may be of interest to you or to provide you with small gifts. We may also encourage you to purchase a product and services when we see you. In addition, we may use and disclose your protected health information for certain marketing activities, such as, using your name and address to send you a newsletter about our office and the services we offer.
Ø Fundraising Activities We may use protected health information about you in order to contact you for fundraising activities supported by us. Only your name, address and phone number and the date you received treatment or services from us would be used.
Ø Individuals Involved in Your Care or Payment for Your Care We may disclose to one of your family members, to a relative, to a close personal friend or to any other person identified by you, protected health information directly relevant to the person’s involvement with your care or payment related to your care. In addition, we may disclose protected health information about you to notify, identify or locate a member of your family, your personal representative, another person responsible for your care or certain disaster relief agencies of your location, general condition or death. In the case of a communication barrier, we may disclose your protected health information to an interpreter.
Ø Emergencies/Disaster Relief We may use or disclose your protected health information about you to a public or private agency (like American Red Cross) for emergencies or disaster relief purposes. Even if you object, we may still share information about you, if necessary for emergency circumstances.
Ø Research/Stem Cell Research Under certain circumstances, we may use and disclose protected health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care.
Ø As Required By Law We will disclose protected health information about you when required to do so by federal, state or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. We will make a reasonable effort to inform you of the request.
Ø To Avert a Serious Threat to Health or Safety We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Ø Military and Veterans If you are a member of the armed forces, we may release protected health information about you as required by military command authorities. We may also release protected health information about foreign military personnel to the appropriate foreign military authority.
National Security and Intelligence Activities We may release protected health information about you to authorized federal officials for intelligence
Ø Protective Services for the President and Others We may disclose protected health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Ø Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Ø Workers’ Compensation We may release protected health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Ø Public Health Risks We may disclose protected health information about you for public health activities to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Ø Health Oversight Activities We may disclose protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Ø Communicable Diseases We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Ø Abuse or Neglect We may disclose your protected health information to a health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Ø Food and Drug Administration We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Ø Law Enforcement We may disclose your protected health information for certain law enforcement purposes, including, but not limited to:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the hospital; and
- In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
Ø Coroners, Medical Examiners and Funeral Directors, Organ/Tissue Donation Organization We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release protected health information to funeral directors as necessary to carry out their duties. If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
ANY OTHER USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION REQUIRES YOUR WRITTEN AUTHORIZATION
Under any circumstances other than those listed above, we will request that you provide us with a written and signed authorization before we use and disclose your protected health information to anyone.
If you sign an authorization allowing us to disclose protected health information about you, in a specific situation, you can later revoke (cancel) your authorization in writing.
If you cancel your authorization in writing, we will not disclose your protected health information about you after we receive your cancellation, except for disclosures, which were already being processed or made before we received your cancellation.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
You have the following rights regarding protected health information we maintain about you:
Ø Right to Inspect and Copy Upon a written request, you have the right to inspect and obtain a copy of your protected health information that may be used to make decisions about your care that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and other records that we use for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable.
To inspect and/or obtain a copy of your protected health information that my be used to make decisions about you, you must submit your request in writing detailing what information you want to inspect or copy to the Privacy Officer/Contact listed on this Notice. If you request a copy of the information, we may charge a reasonable fee as allowed by the Connecticut law for costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to protected health information, you may request that the denial be reviewed. Another licensed health care professional chosen by us will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Ø Right to Amend If you feel that protected health information we have about you in a designated record set is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us.
Your request must be made in writing and you must explain the reasons you believe the information is inaccurate or incomplete for the requested amendment.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the protected health information kept by or for us;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete, in our opinion.
If we deny your request for amendment, we will give you a written denial notice, including reasons for the denial and explain to you that you have the right to submit a written statement disagreeing with the denial. Your letter of disagreement will be attached to your medical record
You should submit your written request for amendment to the Privacy Officer/Contact listed on this Notice
Ø Right to an Accounting of Disclosures You have the right to request an “accounting (report) of certain disclosures.” This is a list of the disclosures we made of protected health information about you. We are not required to account for the following disclosures as stated by the law. For example: disclosures made for treatment, payment or in the process of our healthcare operation, disclosures authorized by you or made directly to you or others involved in your care, disclosures allowed by law when the use and disclosure relates to certain government functions or in other law enforcement custodial situations.
You must submit your request in writing to the Privacy Officer/Contact listed on this Notice. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example: on paper or electronically), and if readily producible, we will comply. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Ø Right to Request Restrictions You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure you had. If for any reason, the restriction or limitation of protected health information results in non-payment, denial of claim, you will be financially responsible for payment of all services rendered to you associated with requested restriction or limitation.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to Privacy Officer/Contact listed in this Notice. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse).
Ø Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
You must make your request in writing to Privacy Officer/Contact listed in this Notice. We will not ask you the reason for your request. We will accommodate all reasonable requests submitted in writing which must specify how or where you wish to be contacted.
Ø Right to a Paper Copy of this Notice You have the right to a paper copy of this notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
To obtain a paper copy of this Notice, contact the Privacy Officer/Contact listed on the first page of this Notice.
Special Rules Regarding Disclosure of Psychiatric, Substance Abuse and HIV Related Information
Under Connecticut or Federal Law, additional restrictions may apply to disclosures of health information that relate to care for psychiatric conditions, substance abuse or HIV related testing and treatment.
This information may not be disclosed without your specific written permission, except as may be specifically required or permitted by Connecticut or Federal Law. The following are examples of disclosures that may be made without your specific written permission:
- Psychiatric information: we may disclose psychiatric information to a mental health program if needed for your diagnosis or treatment. We may also disclose very limited psychiatric information for payment purposes.
- HIV Related information: We may disclose HIV related information for purposes of treatment or payment
- Substance abuse treatment: We may disclose information obtained from a substance abuse program in an emergency.
CHANGES TO THIS NOTICE
We reserve the right to change the terms of this Notice and to make the new provisions of the Notice effective for all protected health information we maintain. A current copy of the Notice shall be posted in this practice’s main office and all satellite sites.
COMPLAINTS You will not be penalized for filing a complaint
If you believe your privacy rights have been violated, you may file a complaint with Privacy Officer/Contact listed on this Notice of Privacy Practices or with the Secretary of the Department of Health and Human Services. All complaints must be in writing and forwarded to the Privacy Officer/Contact listed on the first page of this Notice. To file a complaint with the government you may contact:
Office of Civil Rights
- S. Department of Health and Human Services
200 Independence Ave, SW Room 509F
Washington, DC 20201
OB/GYN of Fairfield County, LLC