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Effective Date: April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORATION. PLEASE REVIEW IT CAREFULLY.
WHO WILL FOLLOW THIS NOTICE?
This notice describes the policies of JSF Inc. (dba Daniel A. Funk MD) and the procedures that will be followed by all physicians, allied health care professionals and staff who handle your medical information. This disclosure has been mandated by The Congress of the United States and conforms to the Health Insurance Portability and Accountability Act (HIPAA) of 1997. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations JSF Inc. (dba Daniel A. Funk MD) has regarding the use and disclosure of medical information.
The HIPPA Law requires us to:
· Make sure that medical information that identifies you is kept private. This law concerns Protected Health Information, which is defined as any individually identifiable health information that is maintained by this practice whether written, oral or electronic.
· Give you this notice of our legal duties and privacy practices with respect to medical information about you
· Follow the terms of the Notice that is currently in effect.
OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We maintain our records with a goal of providing the highest level of protection for your medical information. This notice applies to all of the records of your medical care, which are received or created by JSF Inc. (dba Daniel A. Funk MD). Please realize that your other medical treatment providers (e.g., doctors, hospitals, home health agencies, etc.) may have different policies or notices regarding the use and disclosure of your medical information.
USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
By becoming a patient of JSF Inc. (dba Daniel A. Funk MD), you are giving consent for JSF Inc. dba Daniel A. Funk MD to use your medical information for certain activities, including treatment, payment and other health care operations. We may use and disclose medical information about you so that JSF Inc. (dba Daniel A. Funk MD) and its medical professionals can treat you. We may also use and disclose medical information about you so that we may be paid for the medical treatment we provide you. We may also use and disclose medical information about you for health care operations; in other words, those other tasks that we need to perform to make sure that you are provided the highest quality of medical care. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students and other medical professionals, licensing and certifications, and conducting or arranging for other business activities. We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services, computer security) for the practice. Whenever that arrangement between our office and 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.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN AUTHORIZATION
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization at any time, in writing, except to the extent that your physician and the practice has taken an action in reliance on the use or disclosure indicated in the authorization.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT
We may use and disclose your protected health information in the following instances. You may have the opportunity to agree or object to the use of disclosure of all or part of you protected health information. If you are not present or able to agree or object to the use or disclosure of the information, you physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case only the protected health information that is relevant to your health care will be disclosed.
Others Involved in your care: Unless you object, we may disclose to a member of your family, a relative, close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member or any other person that is responsible for your care of your location, general condition or demise.
Emergencies: We may use or disclose your protected health information in any emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If any physician, or health care professional, in this practice is required by law to treat you and has attempted to obtain your consent but us unable to, he or she may still use or disclose your protected health information to treat you.
Communication barriers: We may use and disclose your protected health information if your physician or health care professional in this practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the health care professional determines, using professional judgment, that you intend to consent to use or disclose under the circumstances.
OTHER PREMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT
We may use or disclose your protected health information in the following situations without your consent or authorization.
Uses and disclosures for health-related benefits or services: From time to time, we may use and disclose medical information to tell you about certain health-related benefits or services that may be of interest to you.
Uses and disclosures as required by law: We will disclose medical information about you when required to do so by federal, state, or local law.
Disclosures for health oversight activities: We may disclose medical information to a health oversight agency for activities authorized by law. These activities include, for example, audits, investigations, and inspections. These activities are necessary for the government to monitor the health care system, the delivery of health care, etc.
Disclosures for lawsuits and disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court order or administrative order. We may also disclose medical 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.
Disclosures to law enforcement: We may release medical information if asked to do so by a law enforcement official, in response to a court order, subpoena, warrant, summons, or similar process. Other related disclosures may include disclosures to national security and intelligence agencies, as well as disclosures to authorized federal officials for the protection of the President of the United States or other authorized persons or foreign heads of state.
Disclosures for public health: We may 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. The disclosure will be made for the purpose of controlling disease, injury or disability. This disclosure includes authorization when indicated by law to a person who may have been exposed to a communicable disease or may other wise be at risk of contracting or spreading the disease or condition.
Health oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse and neglect: We may disclose your protected health information to a public 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.
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, enable product recalls, to make repairs or replacements or to conduct post marketing surveillance as required by law.
Workers compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of your medical information not covered by this notice or the laws that apply to JSF Inc. (dba Daniel A. Funk MD) will be made only with your written permission (“authorization”). If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the medical treatment or other services that we have provided to you.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your medical care. Usually this right includes both medical and billing records. You must submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. Your request to inspect and copy your information may only be denied in very limited circumstances such as in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding which involves your protected health information. You have a right to request that any such denial be reviewed.
Right to Request Restrictions. You have the right to request that we restrict the use and disclosure of your medical information for treatment, payment and health care operations. 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 and 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.
Right to Confidential Communications. You also have the right to request to receive private health information by alternative means or at alternative locations. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing.
We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to Amend. If you feel that the medical information we have about you is incorrect or incomplete, you have the right to request that your medical information be amended. Only the health care entity (e.g., doctor, hospital, clinic, etc.) that created your medical information is responsible for amending it.
Right to an Accounting of Disclosures. You have a right to an accounting of disclosures of your medical information, for purposes other than treatment, payment or health care operations by JSF Inc. (dba Daniel A. Funk MD) or any of the people or companies who perform treatment, payment or health care operations on our behalf. To request this list of disclosures we made of medical information about you, you must submit a request in writing. Your request must state a time period, which may not be longer than six (6) years prior to the date of your request and may not include dates before April 14, 2003.
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.
CHANGES TO THIS NOTICE
JSF Inc. (dba Daniel A. Funk MD) reserves the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we create or receive in the future. The notice will contain, in the top right-hand corner, the effective date.
FURTHER INFORMATION AND COMPLAINTS
If you want to learn more about these procedures, if you believe your privacy rights have been violated and/or that JSF Inc. (dba Daniel A. Funk MD) has not followed this policy, you may file a complaint with JSF Inc. (dba Daniel A. Funk MD) or with the Secretary of the Department of Health and Human Services. To file a complaint with, contact:
Daniel A. Funk MD
2123 Auburn Ave. Suite 322
Cincinnati, Ohio 45219
All complaints must be submitted in writing. You will not be penalized for filing a complaint.
