NOVEMBER 2014 NOTICE OF PRIVACY PRACTICES
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.
WHO WILL FOLLOW THIS NOTICE
This notice describes the information privacy practices followed by our employees, staff and other personnel.
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about you and to the health care and services you receive from Jackrabbit Family Medicine (“JFM”) and Camelback Family Planning (“CFP”). We are required by law to give you this notice. It describes the ways we may use and disclose your health information. It also describes your rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
- For Treatment. We may use your health information to provide you with medical treatment or services. We may disclose your health information to doctors, nurses, technicians, staff or other personnel who are involved in your care.
- For Payment. We may use and disclose your health information so that treatment and services you receive at JFM/CFP may be billed to and payment may be collected from you, and insurance company or a third party.
- For Health Care Operations. We may use and disclose your health information in order to run JFM/CFP and make sure that you and other patients receive quality care. We may also disclose your health information to health plans that provide you insurance coverage and other health care providers that care for you.
We may use or disclose your health information for the following purposes, subject to all applicable legal requirements and limitations:
- To Avert Serious Threat to Health or Safety. We may use and disclose your health information to prevent serious threat to your health and safety or the health and safety of the public or another person.
- Required By Law. We will disclose your health information when required to do so by federal, state or local law.
- Research. We may use and disclose your health information for research projects that are subject to a special approval process. We will ask you for your permission if the researcher will have access to your name, address or other information that reveals who you are.
- Organ and Tissue Donation. If you are an organ donor, we may release health information to organizations that handle organ procurement or transplantation or to an organ donation bank.
- Military, Veterans, National Security and Intelligence. If you are or were a member of the armed forces, national security or intelligence communities, we may be required by military command or other government authorities to release your health information.
- Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs.
Public Health Risks. We may disclose your health information for public health reasons to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
- Health Oversight Activities. We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes.
- Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose your health information in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose your health information in response to subpoena.
- Law Enforcement. We may release health information if asked by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
- Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner, medical examiner or funeral director.
- Information Not Personally Identifiable. We may use or disclose your health information in a way that does not personally identify you or reveal who you are.
- Family and Friends. We may disclose your health information to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific written Authorization. We also will not use or disclose your health information for the following purposes without your specific written Authorization:
- For Marketing Purposes. This does not include face-to-face communication about your prescriptions or products and services which may benefit you.
- For the Purpose of Selling Your Health Information. We may receive payment for sharing your information for public health purposes, research, or releases to you or others you authorize release to, as long as payment is reasonable and related to the cost of providing your health information.
- Any Disclosure of Your Psychotherapy Notes. These are the notes that your behavioral health provider maintains that record your appointments with your provider and are not stored with your medical record.
If you give us Authorization to use or disclose your health information, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.
In some instances, we may need specific written authorization from you in order to disclose certain types of specially-protected information such as psychotherapy notes, HIV, substance abuse, mental health, and genetic testing information for purposes such as treatment, payment and healthcare operations.
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information (“PHI”) 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 disclose your PHI to disaster relief organizations that seek your PHI to coordinate your care, or notify family and friends or your location or condition in a disaster.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
- Right to Inspect and Copy. You have the right to inspect and copy your health information. You must submit a written request to Gabrielle Goodrick MD in order to inspect and/or copy records of your health information. We may charge a fee for the costs of copying and mailing. We will notify you of the cost involved and you may choose to modify or withdraw your request at that time. You have the right to request a copy of your health information in electronic form if we store your health information electronically.
- Right to Amend. You have the right to request that we amend your health information. Your request for an amendment must be submitted in writing and detail what information is inaccurate and why. A request for amendment does not necessarily indicate the information will be amended.
- Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures”. This is a list of the disclosures we made of your medical information for purposes other than treatment, payment, health care operations, when specifically authorized by you and a limited number of special circumstances involving national security, correctional institutions and law enforcement. Submit your request in writing to Gabrielle Goodrick MD.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the on the health information we use or disclose about you for treatment, payment or health care operations. We are required to agree to your request if you pay for treatment, services, supplies and prescriptions “out of pocket” and you request the information not be communicated to your health plan for payment or health care operations purposes. There may be instances where we are required to release this information if required by law. To request restrictions, you may complete and submit the Request for Restriction on Use/Disclosure of Medical Information to Gabrielle Goodrick, MD.
- 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. To request confidential communications, you may complete and submit the Request for Restriction on Use/Disclosure of Medical Information and/or confidential Communication to Gabrielle Goodrick, MD. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- 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 paper copy of this notice at any time. You may also find this notice on our website.
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make the revised notice effective for medical information we already have about you as well as any information we receive in the future. We will post the current notice at our location and on our website with its effective date in the top center.
BREACH OF HEALTH INFORMATION
We will inform you if there is a breach of your health information.
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services at:
Office for Civil Rights Region IX, US Department of Health & Human Services
90 7th Street, Suite #4-100
San Francisco, CA 94103
To file a complaint with Jackrabbit Family Medicine/Camelback Family Planning, contact:
Gabrielle Goodrick, MD
4141 N 32nd Street, Suite 105
Phoenix, AZ 85018
You will not be penalized for filing a complaint.