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This notice describes how medical information
about you may be used and disclosed and how to get access to this
information. Please read it carefully.
Mid Atlantic Retina
is required by the federal privacy rule to maintain the privacy
of your health and to provide you with notice of our legal duties
and privacy practices with respect to your protected health care
information.
What is Protected
Health Information (PHI)?
Your protected health information is any information that relates
to your past, present or future physical or mental health or condition,
the provision of health care to you, or payment for health care
provided to you, and individually identifies you or reasonably can
be used to identify you. Your medical and billing records at our
practice are examples of information that usually will be regarded
as your protected health information.
How we may use and disclose individual
protected health information
A. We may use and disclose your
protected health information for treatment, payment and other
health care operations without your authorization.
- Treatment – We may
use and disclose your PHI for the purpose of treating you. Treatment
includes the provision, coordination, or management of health
care services to you by one or more health care providers. Some
examples of treatment uses and disclosures include, but are not
limited to:
- We may use a patient sign-in sheet at the reception
desk.
- We may ask you to confirm or update personal
health, insurance or demographic information while in the
office.
- We may call patients by name in the waiting
area when it is time to go to an exam room.
- During an office visit, our physicians and
staff involved in your care may review your medical record
and share and discuss your medical information with each other.
- We may share and discuss your medical information
with an outside physician to whom we have referred you for
care or with whom we are consulting regarding you.
- We may share and discuss your medical information
with a hospital or other health care provider who seeks information
for the purpose of treating you.
- We may contact you via telephone or mail with
notices regarding an appointment. We may leave the telephone
message with someone at your telephone number, or leave the
message on your answering machine.
- We cannot guarantee your privacy if you choose
to discuss your condition or symptoms in a public area inside
or outside our office.
- Payment - We may use and
disclose your PHI for our payment purposes as well as the payment
purposes of other health care providers and health plans. Some
examples of payment uses and disclosures include, but are not
limited to:
- We may share information with or request it
from your health insurer to determine whether you are eligible
for coverage or whether proposed treatment is a covered service.
- We may submit a claim to your health insurer
for payment, or provide supplemental information to your health
insurer so that reimbursement can be obtained under a coordination
of benefits clause you may have in your subscriber agreement.
- We may share demographic information such as
your address or insurance identification number, with other
health care providers who seek this information to obtain
payment for health care services provided to you.
- We may mail you bills, refunds or receipts
in envelopes with our practice name and return address.
- We may provide a bill to a family member or
other person designated as responsible for payment for services
rendered to you.
- We may provide medical records and other related
documentation to your health insurer to support the medical
necessity of services provided to you. We may allow your health
insurer access to your medical record for a medical necessity
or quality review audit.
- We may provide information to our collection
agency or our attorney in a legal action for purposes of securing
payment of a delinquent account.
- Health Care Operations –
We may use and disclose your PHI for other health care related
purposes for our practice or that of other health care providers
and health plans. Some examples may include, but are not limited
to:
- Quality assessment or improvement activities.Activities
related to improving health or reducing health care costs
of our patient population.
- Reviewing the competence, qualifications, or
performance of health care professionals.
- Conducting training programs for medical and
other students.
- Business planning and development activities,
such as conducting cost management and planning related analyses.
- Health care fraud and abuse detection and compliance
programs as well as other medical review, legal services,
and auditing functions.
- Accreditation, certification, licensing, and
credentialing activities.
- Other business management and general administrative
activities, such as compliance with federal privacy rule and
resolution of patient grievances.
B. Other Uses and Disclosures
of Your PHI for which your written authorization is not required.
- We may disclose information to individuals
involved in your care or responsible for the payment of your care.
We may disclose your PHI to someone involved in your care or payment
of your care, such as a spouse, a family member, or close friend.
For example, if you are having surgery, we may discuss any physical
limitations with a family member assisting in your post-operative
care.
- We may disclose your information for notification
purposes. We may use and disclose your PHI to notify,
or to assist in the notification of a family member, a personal
representative, or another person responsible for your care, regarding
your location, general condition, or death. For example, if you
are hospitalized, we may notify a family member of the hospital
and your general condition. In addition, we may disclose your
PHI to a disaster relief entity, such as the Red Cross, so that
it can notify a family member, a personal representative, or another
person involved in your care regarding your location, general
condition, or death.
- We may disclose your information
as required by law and for other public health activities.
We may use and disclose your PHI when required by federal, state,
or local law and for public health activities. Examples may include:
- Mandatory reporting requirements involving
births and deaths.
- Victims of abuse, neglect or domestic violence.
- Disease prevention and control, or the reporting
of a communicable disease.
- Vaccine-related injuries, medical device-related
deaths and serious injuries.
- Gunshot and other injuries by a deadly weapon
or criminal act.
- Driving impairments, and blood alcohol testing.
- FDA-related reports.
- OSHA requirements for workplace surveillance
and injury reports.
- Health oversight activities such as audits,
inspections, investigations, licensure actions, and legal
proceedings.
- Judicial and administrative proceedings in
response to a court order or subpoena, discovery request or
other lawful process.
- Coroners, medical examiners or funeral directors
for the purpose of identifying a deceased patient, determining
cause of death, or as required by law.
- Facilitating organ, eye and tissue donation
or for procurement, banking or transplantation of cadaveric
organs, eyes, or tissue.
- Public safety threats, including protection
of a third party from harm, and identification and apprehension
of a criminal or to protect someone from imminent serious
harm.
- Purposes involving specialized government functions.
- Compliance with laws relating to workers’
compensation or similar programs established by law, that
provide benefits for work-related injuries or illness without
regard to fault.
- Functions performed by a business associate
such as a billing company, accountant or law firm.
- Purpose of removing your protected health information
to allow disclosure without your authorization.
- Incidental disclosures which result as a by-product
of an otherwise permitted use or disclosure, such as other
patients hearing your name being called in the waiting room
or seeing your name on the sign-in sheet.
We may need to use and disclose your PHI for
other reasons with your authorization. For any and all
other uses of your protected health information which are not listed
in this notice, we will obtain your written authorization. For example,
if you wish to have your medical records released to another physician
not directly involved with us for your treatment. Your authorization
can be revoked at any time but is limited to present and future
protected health information releases only. A revocation form is
available upon request from the Privacy Officer. The form must be
completed by you and returned to the Privacy Officer. You cannot
revoke an authorization for information previously released.
Your patient rights regarding
your privacy
- You have a right to restrict the use of
disclosure of your PHI. You have a right to request that
we further restrict use and disclosure of your PHI for treatment,
payment, or health care operations or to someone who is involved
in your care or the payment for your care, or for notification
purposes. While we will consider all requests for restrictions
carefully, we are not required to agree to or accommodate your
request if it is deemed by us as unreasonable.
- You have the right to confidential communication
of your PHI. You have a right to request that we communicate
your protected health information to you by a certain means or
at a certain location. For example, you may instruct us not to
contact you by telephone at your place of work.
- You have the right to a listing of disclosures
of your PHI. You may obtain, upon request, a record of
certain disclosures of your PHI. We do not have to account for
disclosures made for purposes of treatment, payment, or health
care operations, to persons assisting in your care, or those disclosures
made prior to an authorization, among others. Your request may
cover any disclosures made in the six years prior to the date
of your request. However, we are not required to five you a record
of disclosures that occurred prior to April 14, 2003. In some
circumstances, we may charge you for providing this listing.
- You have the right to inspect and copy
your PHI. You have a right to inspect and obtain a copy
of your PHI that we maintain in your designated medical records.
This right is subject to limitations and we may charge you in
accordance with your state law.
- You have the right to amend your PHI.
You have a right to request that we amend PHI maintained in your
medical or billing records if the information is incorrect or
incomplete. This request to subject to limitations.
Any requests to restrict, amend,
inspect or copy your personal health information must be submitted
in writing to our Privacy Officer.
Changes to this notice
We reserve the right
to change this notice at any time. We further reserve the right
to make any change effective for all protected health information
that we maintain at the time of the change – including
information that we created or received prior to the effective date
of the change. We will post a copy of our current notice in the
waiting room of our practice. Patients may also access our current
notice of privacy practices on our web site at www.midatlanticretina.com.This
notice is regarding your rights related to the federal privacy rule.
It is not intended to create contractual or other rights independent
of those created in the federal privacy rule. If you believe that
we have violated your privacy rights, you may submit a complaint,
in writing, to our Privacy Officer at:
Mid Atlantic Retina
Attention: Privacy Officer
910 E. Willow Grove Ave
Wyndmoor, PA 19038
215-233-4300 (tel)
215-836-1991 (fax)
Additionally, you may also file a written
complaint with the Director, Office for Civil Rights of the U.S.
Department of Health and Human Services. Upon request, the Privacy
Officer will provide you with the correct address for the Director.
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