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Obstetrics
& Gynecology Of Atlanta, P.C.
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OBSTETRICS & GYNECOLOGY OF
ATLANTA, P.C.
NOTICE OF PRIVACY
PRACTICES
As Required by the
Privacy Regulations Created as a Result of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA)
This notice describes
how health information about you (as a patient of this practice) may
be used and disclosed, and how you can get access to your
individually identifiable health information.
PLEASE REVIEW THIS
NOTICE CAREFULLY.
A. OUR COMMITMENT TO
YOUR PRIVACY
Our practice is
dedicated to maintaining the privacy of your individually
identifiable health information (IIHI). In conducting our business,
we will create records regarding you and the treatment and services
we provide to you. We are required by law to maintain the
confidentiality of health information that identifies you. We also
are required by law to provide you with this notice of our legal
duties and the privacy practices that we maintain in our practice
concerning your IIHI. By federal and state law, we must follow the
terms of the notice of privacy practices that we have in effect at
the time.
We realize that these
laws are complicated, but we must provide you with the following
important information:
-
How we may use and
disclose your IIHI
-
Your privacy rights in
your IIHI
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Our obligations
concerning the use and disclosure of your IIHI
The terms of this notice
apply to all records containing your IIHI that are created or
retained by our practice. We reserve the right to revise or amend
this Notice of Privacy Practices. Any revision or amendment to this
notice will be effective for all of your records that our practice
has created or maintained in the past, and for any of your records
that we may create or maintain in the future. Our practice will
post a copy of our current Notice in our offices in a visible
location at all times, and you may request a copy of our most
current Notice at any time.
B. IF YOU HAVE
QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Leslie Graham
678-686-8618
975 Johnson Ferry Road,
Suite 400 Atlanta, Georgia 30342
C. WE MAY USE AND
DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN
THE FOLLOWING WAYS
The following categories
describe the different ways in which we may use and disclose your
IIHI.
1. Treatment.
Our practice may use your IIHI to treat you. For example, we may
ask you to have laboratory tests (such as blood or urine tests), and
we may use the results to help us reach a diagnosis. We might use
your IIHI in order to write a prescription for you, or we might
disclose your IIHI to a pharmacy when we order a prescription for
you. Many of the people who work for our practice – including, but
not limited to, our doctors and nurses – may use or disclose your
IIHI in order to treat you or to assist others in your treatment.
We may also disclose your IIHI to other health care providers for
purposes related to your treatment.
2. Payment. Our
practice may use and disclose your IIHI in order to bill and collect
payment for the services and items you may receive from us. For
example, we may contact your health insurer to certify that you are
eligible for benefits (and for what range of benefits), and we may
provide your insurer with details regarding your treatment to
determine if your insurer will cover, or pay for, your treatment.
We also may use and disclose your IIHI to obtain payment from third
parties that may be responsible for such costs, such as family
members. Also, we may use your IIHI to bill you directly for
services and items. We may disclose your IIHI to other health care
providers and entities to assist in their billing and collection
efforts.
3. Health Care
Operations. Our practice may use and disclose your IIHI to
operate our business. As examples of the ways in which we may use
and disclose your information for our operations, our practice may
use your IIHI to evaluate the quality of care you received from us,
or to conduct cost-management and business planning activities for
our practice. We may disclose your IIHI to other health care
providers and entities to assist in their health care operations.
4. Appointment
Reminders. Our practice may use your IIHI to contact you and
remind you of an appointment.
5. Disclosures
Required By Law. Our practice will use and disclose your IIHI
when we are required to do so by federal, state or local law.
D. USE AND DISCLOSURE
OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories
describe unique scenarios in which we may use or disclose your
identifiable health information:
1. Public Health
Risks. Our practice may disclose your IIHI to public health
authorities that are authorized by law to collect information for
the purpose of:
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maintaining vital
records, such as births and deaths
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reporting child abuse
or neglect
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preventing or
controlling disease, injury or disability
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notifying a person
regarding potential exposure to a communicable disease
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notifying a person
regarding a potential risk for spreading or contracting a disease
or condition
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reporting reactions to
drugs or problems with products or devices
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notifying individuals
if a product or device they may be using has been recalled
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notifying appropriate
government agency(ies) and authority(ies) regarding the potential
abuse or neglect of an adult patient (including domestic
violence); however, we will only disclose this information if the
patient agrees or we are required or authorized by law to disclose
this information
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notifying your
employer under limited circumstances related primarily to
workplace injury or illness or medical surveillance.
2. Health Oversight
Activities. Our practice may disclose your IIHI to a health
oversight agency for activities authorized by law. Oversight
activities can include, for example, investigations, inspections,
audits, surveys, licensure and disciplinary actions; civil,
administrative, and criminal procedures or actions; or other
activities necessary for the government to monitor government
programs, compliance with civil rights laws and the health care
system in general.
3. Lawsuits and
Similar Proceedings. Our practice may use and disclose your
IIHI in response to a court or administrative order, if you are
involved in a lawsuit or similar proceeding. We also may disclose
your IIHI in response to a discovery request, subpoena, or other
lawful process by another party involved in the dispute, but only if
we have made an effort to inform you of the request or to obtain an
order protecting the information the party has requested.
4. Law Enforcement.
We may release IIHI if asked to do so by a law enforcement official:
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Regarding a crime
victim in certain situations, if we are unable to obtain the
person’s agreement
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Concerning a death we
believe has resulted from criminal conduct
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Regarding criminal
conduct at our offices
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In response to a
warrant, summons, court order, subpoena or similar legal process
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To identify/locate a
suspect, material witness, fugitive or missing person
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In an emergency, to
report a crime (including the location or victim(s) of the crime,
or the description, identity or location of the perpetrator).
5. Research.
Our practice may use and disclose your IIHI for research purposes in
certain limited circumstances. We will obtain your written
authorization to use your IIHI for research purposes except when an
Institutional Review Board or Privacy Board has determined that the
waiver of your authorization satisfies the following: (i) the use
or disclosure involves no more than a minimal risk to your privacy
based on the following: (A) an adequate plan to protect the
identifiers from improper use and disclosure; (B) an adequate plan
to destroy the identifiers at the earliest opportunity consistent
with the research (unless there is a health or research
justification for retaining the identifiers or such retention is
otherwise required by law); and (C) adequate written assurances that
the PHI will not be re-used or disclosed to any other person or
entity (except as required by law) for authorized oversight of the
research study, or for other research for which the use or
disclosure would otherwise be permitted; (ii) the research could not
practicably be conducted without the waiver; and (iii) the research
could not practicably be conducted without access to and use of the
PHI.
6. Serious Threats
to Health or Safety. Our practice may use and disclose your
IIHI when necessary to reduce or prevent a serious threat to your
health and safety or the health and safety of another individual or
the public. Under these circumstances, we will only make
disclosures to a person or organization able to help prevent the
threat.
7. Military.
Our practice may disclose your IIHI if you are a member of U.S. or
foreign military forces (including veterans) and if required by the
appropriate authorities.
8. National Security.
Our practice may disclose your IIHI to federal officials for
intelligence and national security activities authorized by law. We
also may disclose your IIHI to federal officials in order to protect
the President, other officials or foreign heads of state, or to
conduct investigations.
9. Inmates. Our
practice may disclose your IIHI to correctional institutions or law
enforcement officials if you are an inmate or under the custody of a
law enforcement official. Disclosure for these purposes would be
necessary: (a) for the institution to provide health care services
to you, (b) for the safety and security of the institution, and/or
(c) to protect your health and safety or the health and safety of
other individuals.
10. Workers’
Compensation. Our practice may release your IIHI for workers’
compensation and similar programs.
E. YOUR RIGHTS
REGARDING YOUR IIHI
You have the following
rights regarding the IIHI that we maintain about you:
1. Confidential
Communications. You have the right to request that our practice
communicate with you about your health and related issues in a
particular manner or at a certain location. For instance, you may
ask that we contact you at home, rather than work. In order to
request a type of confidential communication, you must make a
written request to Leslie Graham 678-686-8618 specifying the
requested method of contact, or the location where you wish to be
contacted. Our practice will accommodate reasonable requests. You
do not need to give a reason for your request.
2. Requesting
Restrictions. You have the right to request a restriction in
our use or disclosure of your IIHI for treatment, payment or health
care operations. Additionally, you have the right to request that
we restrict our disclosure of your IIHI to only certain individuals
involved in your care or the payment for your care, such as family
members and friends. We are not required to agree to your request;
however, if we do agree, we are bound by our agreement except when
otherwise required by law, in emergencies, or when the information
is necessary to treat you. In order to request a restriction in our
use or disclosure of your IIHI, you must make your request in
writing to Leslie Graham 678-686-8618. Your request must
describe in a clear and concise fashion:
(a) the
information you wish restricted;
(b)
whether you are requesting to limit our practice’s use, disclosure
or both
(c) to whom you
want the limits to apply.
3. Inspection and
Copies. You have the right to inspect and obtain a copy of the
IIHI that may be used to make decisions about you, including patient
medical records and billing records, but not including psychotherapy
notes. You must submit your request in writing to Leslie Graham
678-686-8618 in order to inspect and/or obtain a copy of your
IIHI. Our practice may charge a fee for the costs of copying,
mailing, labor and supplies associated with your request. Our
practice may deny your request to inspect and/or copy in certain
limited circumstances; however, you may request a review of our
denial. Another licensed health care professional chosen by us will
conduct reviews.
4. Amendment.
You may ask us to amend your health information if you believe it is
incorrect or incomplete, and you may request an amendment for as
long as the information is kept by or for our practice. To request
an amendment, your request must be made in writing and submitted to
Leslie Graham 678-686-8618. You must provide us with a
reason that supports your request for amendment. Our practice will
deny your request if you fail to submit your request (and the reason
supporting your request) in writing. Also, we may deny your request
if you ask us to amend information that is in our opinion: (a)
accurate and complete; (b) not part of the IIHI kept by or for the
practice; (c) not part of the IIHI which you would be permitted to
inspect and copy; or (d) not created by our practice, unless the
individual or entity that created the information is not available
to amend the information.
5. Accounting of
Disclosures. All of our patients have the right to request an
“accounting of disclosures.” An “accounting of disclosures” is a
list of certain non-routine disclosures our practice has made of
your IIHI for non-treatment, non-payment or non-operations
purposes. Use of your IIHI as part of the routine patient care in
our practice is not required to be documented. For example, the
doctor sharing information with the nurse; or the billing department
using your information to file your insurance claim. In order to
obtain an accounting of disclosures, you must submit your request in
writing to Leslie Graham via fax at 404-252-6794. All
requests for an “accounting of disclosures” must state a time
period, which may not be longer than six (6) years from the date of
disclosure and may not include dates before April 14, 2003. The
first list you request within a 12-month period is free of charge,
but our practice may charge you for additional lists within the same
12-month period. Our practice will notify you of the costs involved
with additional requests, and you may withdraw your request before
you incur any costs.
6. Right to a Paper
Copy of This Notice. You are entitled to receive a paper copy
of our notice of privacy practices. You may ask us to give you a
copy of this notice at any time. To obtain a paper copy of this
notice, request one from any of our receptionists or contact
Leslie Graham 678-686-8618.
7. Right to File a
Complaint. If you believe your privacy rights have been
violated, you may file a complaint with our practice or with the
Secretary of the Department of Health and Human Services. To file a
complaint with our practice, contact Leslie Graham 678-686-8618.
All complaints must be submitted in writing. You will not be
penalized for filing a complaint.
8. Right to Provide
an Authorization for Other Uses and Disclosures. Our practice
will obtain your written authorization for uses and disclosures that
are not identified by this notice or permitted by applicable law.
Any authorization you provide to us regarding the use and
disclosure of your IIHI may be revoked at any time in writing.
After you revoke your authorization, we will no longer use or
disclose your IIHI for the reasons described in the authorization.
Please note, we are required to retain records of your care.
Again, if you have any
questions regarding this notice or our health information privacy
policies, please contact Leslie Graham 678-686-8618.
OBSTETRICS & GYNECOLOGY OF
ATLANTA, P.C.
RECEIPT OF NOTICE OF
PRIVACY PRACTICES
WRITTEN ACKNOWLEDGEMENT
FORM.
I,
____________________________, have received a copy of OBSTETRICS &
Patient Printed Name
GYNECOLOGY OF ATLANTA, P.C.’s
Notice of Privacy Practices.
_______________________ _______________
________________
Patient Signature
Birth Date
Date
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