CARROLLTON OBSTETRICS AND GYNECOLOGY

Notice of Privacy Practices

Effective April 14, 2003

Please Review Carefully

 

This Privacy Notice describes how medical information about you (as a patient) of Carrollton OB/GYN may be used and disclosed and how you can get access to this information.

 

The Health Insurance & Accountability Act of 1996 is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential.This Act gives you, the patient, significant new rights to understand and control how your health information is used.

 

OUR COMMITMENT TO YOUR PRIVACY

Carrollton OB/GYN is committed to maintaining the privacy of your protected health information (PHI).As we provide treatment and services to you, we create records that contain your medical and personal information, referred to as protected health information, or PHI.The terms of this Privacy Notice apply to all records containing your PHI that are created or retained by Carrollton OB/GYN.We are required by federal and state law to maintain the privacy of your PHI maintained in such records.We are also required by law to provide you with this Privacy Notice of our legal duties and the privacy practices that we maintain in our office concerning your PHI.We must follow the terms of the Privacy Notice that we have in effect at the time.We reserve the right to revise or amend the Privacy Notice.Any revision or amendment to this Privacy Notice will be effective for all of your records that our office has created or maintained in the past, and for any of your records that we may create or maintain in the future.Carrollton OB/GYN will present to all patients a copy of our current notice, and patients may request a copy of our most current Notice at any time.

 

WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS(TPO)

***** Treatment---means providing, coordination, or managing health care and related services by one or more health care providers.An example of this would include a physical examination..

*****Payment-----means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities and utilization review.An example of this would be sending a bill for your visit to your insurance company for payment.

*****Health Care Operations---includes the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service.An example of this would be an internal quality assessment review.

*****We may also create and distribute de-identified health information by removing all references to individually identifiable information.

*****We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

*****We may release your PHI to a friend or family member who is involved in your care, or who assists in taking care of you. We may also give information to someone who pays, or helps pay, for your medical care.

*****We will disclose PHI when required to do so by federal, state or local law.

*****We will disclose your PHI to public health government authorities that are authorized by law to collect information for purposes such as, but not limited to, the following: Maintain vital records, such as births and deaths

Reporting child abuse or neglect

Preventing or controlling disease, injury or disability

Notifying a person regarding potential exposure to a

communicable disease

Notifying a person regarding a potential risk for spreading

or contracting a disease or condition

Reporting reactions to drugs or problems with products or devices

Notifying individuals if a product or device they may be using has

been recalled

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

Notifying your employer under limited circumstances required by

law primarily relating to workplace injury, illness or medical

surveillance

In response to a court or administrative order, if you are involved

in a law suit or similar proceeding, subpoena, or other lawful

processes

If ask to do so by law enforcement, coroners, medical examiners

and funeral directors

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

As required by the military, national security, federal officials,

  correctional institutions and law enforcement

For workers compensation and similar programs

*****We will use your PHI for purpose of proper medical treatment. We will give the PHI, including medical history and all test and lab results, of all pregnant patients directly to the birthing hospital, babys pediatrician and other specialist needed for the babys care.

 

YOUR RIGHTS REGARDING YOUR PHI

*****To request a restriction on our use and disclosure of your PHI for treatment,

payment or healthcare operations. Additionally, you have the right to request that

we restrict our disclosure of your PHI 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. Your request must be described in a clear

fashion: (a) The information you wish restricted and how you want it restricted

(b) To whom you want the limits to apply

*****To request Carrollton OB/GYN communicate with you about your health and

related issues in a particular manner. We will accommodate reasonable request,

but we are not required to accommodate all request

*****To inspect and obtain a copy of the PHI that we maintain about you, including

patient medical records and billing records, but not including certain other

information that may be restricted by law or pursuant to a legal or administrative

process or proceeding. Our Practice may charge a fee for the cost of copying,

mailing, labor and supplies associated with your request in accordance with

Georgia law

*****To amend the PHI we have about you if you feel your PHI is incorrect or

incomplete. You have the right to request an amendment for as long as

the information is kept by or for this Practice. We may deny your request for an

amendment if it is not in writing and if you fail to provide a reason for the

amendment. In addition we may deny your request if you ask us to amend

information that:

1.      Was not created by Carrollton OB/GYN, unless the person or entity that

created the information if no longer available to make the amendment.

2.      Is not part of the medical information kept by or for Carrollton OB/GYN.

3.      Is not part of the information you would be permitted to inspect or copy.

4.      Is accurate and complete.

*****To request an accounting of disclosures. In order to obtain an accounting of disclosures, you must submit your request in writing. All request for an accounting of disclosures must state a time period, which may not be longer that six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a twelve (12) month period is free of charge. Carrollton OB/GYN will notify you of the costs involved with additional request, and you may withdraw or modify your request before you incur any costs. We are not required to provide you with an accounting of the following disclosures:

1.      For treatment, payment or the healthcare operations of our Practice

2.      Incident to uses and disclosures of your information for permitted purposes

3.      Disclosures you have authorized us to make

4.      Disclosures to others involved in your care; or for notifying a family

member or personal representative about your general condition, location

or death when you have had the opportunity to agree to such disclosures

(or they were otherwise permitted)

5.      Disclosures for national security or law enforcement

6. Disclosures that were part of a imited Date Set(which is a set of

information containing only limited amounts of identifiable information,

as permitted by the HIPAA Privacy Rules)

7.      Disclosures that occurred prior to April 14, 2003

**** You are entitled to receive a paper copy of our notice of privacy practices.Youmay ask us to give you a copy of this notice at any time.

*****The right to file a complaint if you believe your privacy rights have been violated by Carrollton OB/GYN or an employee of our Practice. You may file a complaint with our Chief Privacy Officer or the Secretary of the Department of Health and Human Services. Because we are always interested in improving the quality of services provided to you, we would encourage you to contact our Chief Privacy Officer with any complaints.

*****The right to provide an authorization for other uses and disclosures that are not identified by this Notice or permitted or required by applicable law.

 

 

 

ALL REQUEST MUST BE IN WRITING TO: Velvie Burson

Chief Privacy Officer

156 Clinic Ave

Carrollton, GA 30117