NOTICE OF PRIVACY PRACTICES

Notice of Privacy Practices Print

Effective date June 1, 2007

Purpose

This Privacy Notice is required by the Privacy Regulations stemming from the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This Privacy Notice explains to you, a patient of this practice, how your medical information may be used and disclosed, and how you can get access to your medical information. Please review it carefully.

1. OUR COMMITMENT TO YOU REGARDING MEDICAL INFORMATION
This practice is determined to protect the privacy of your medical information. In order to provide you with quality care and service, as well as comply with the law, we must create a medical record for you and document the care and services you receive at this practice. Federal law requires us to ensure the confidentiality of your medical record. This notice will explain to you which circumstances require us to use or disclose your medical information. We also describe your rights, as well as our obligations, regarding the use and disclosure of medical information.

2. WHAT THE LAW REQUIRES US TO DO
The Federal Law requires us to:

• Keep your medical information private.
• Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
• Follow the terms of the notice that is now in effect.

We have the right to:

• Change our privacy practices and the terms of this notice at any time, provided that the law permits the changes.
• Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.
• Notice of Change to Privacy Practices: Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
Following is a description of the different circumstances that may require this practice to use or disclose your medical information. For any of these circumstances, you can submit a written request restricting our use or disclosure of your medical information for treatment, payment, or healthcare operations. You may also request (in writing) that we disclose your medical information only to certain individuals responsible for your care or the payment for your care. Legally we are not required to agree to your request. If we do agree to honor the written request, then we must abide by our agreement unless in those situations required by law, in emergencies, or when information is necessary to treat you. If you wish to revoke any previously written request, you may do so in writing.

FOR TREATMENT:
We may use your health information to provide you with medical treatment or services, such as sharing medical data with another provider, making referrals, and placing lab and prescription orders. We may disclose your health information to those people who are responsible for your care, for instance, your doctors, nurses, technicians, medical students, or any other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you.

FOR PAYMENT:
We may use and disclose your health information for payment purposes. For instance, we may need to give your health insurance plan information about a treatment you received at our practice when filing a claim, so that your health plan can either pay us or reimburse you for your payment. We may also tell your health plan about a treatment you are going to receive to get approval or to determine if your plan will pay for the treatment.

FOR HEALTH CARE OPERATIONS:
We may use and disclose your health information for our healthcare operations. This includes quality assurance, employee performance evaluations, conducting training programs, and getting accreditation, licensure, and credentialing.

ADDITIONAL USES AND DISCLOSURES:
In addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purposes.
Medical information to notify or help notify:

• A family member
• Your personal representative
• Another person responsible for your care

We will share information about your location and general condition. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up devices and supplies.

b. Disaster Relief:
We may share medical information with a public or private organization or person who can legally assist in disaster relief efforts.

c. Specialized Military Personnel Functions:
Your medical information may be disclosed if you are military personnel, either active status or a veteran, and if required by the appropriate authorities.

d. Public Health Activities:
Your medical information may be disclosed if required to do so by a public health or law enforcement official whose job is to prevent or control disease, injury or disability. Your medical information may also be disclosed to a person from the Food and Drug Administration for the purposes of reporting adverse effects stemming from product defects or problems, to enable product recalls, repairs or replacements, or to conduct activities required by the Food and Drug Administration.

e. Personal Health and Safety:
Your medical information may be disclosed when necessary to prevent a serious threat to your health and safety or the health and safety of another individual or the public. The information will be disclosed only to a person or organization able to prevent the threat.

f. Workers Compensation:
Your medical information may be disclosed when necessary to comply with the laws for the Workers Compensation Program.

g. Public Health Oversight Activities:
Your medical information may be disclosed to public health authorities and health oversight agencies that are authorized by law to gather health information (e.g. audits, licensure, disciplinary actions, administrative and criminal investigations, etc.)
h. Law Enforcement:
Your health information may be disclosed in response to a court or administrative order in a lawsuit or similar proceeding.

4. YOUR INDIVIDUAL RIGHTS
You Have the Right to:

• Look at or get copies of your medical records on file. You have the right to receive a copy of the Privacy Notice. To receive a copy, please notify the receptionist.
  
• Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions. Request that we place additional restrictions on our use or disclosure of your medical information.
  
• We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).
  
• Request that we communicate with you about your medical information by different means or to different locations. Your request that we communicate your medical information to you by different means or different locations must be made in writing to the contact person listed at the end of this notice.
  
• Ask to change your health information if you think it is incomplete or inaccurate. The request must be made in writing to the contact person listed at the end of this notice. If, however, the physician or hearing health care professional finds that the patients health information is complete and accurate, he/she can refuse to make the requested changes.
  
• If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the contact person listed at the end of this notice.

5. QUESTIONS AND COMPLAINTS
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Dr. Bettie Borton – HIPAA Privacy Officer
(334) 396-1635 or bchampion1@aol.com
If you think that we may have violated your privacy rights, contact the person named above. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.

6. ACKNOWLEDGEMENT FORM
I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Name:
Signature:
Date:

The Privacy Rule portion of the HIPAA regulations requires our practice to submit a copy of the Privacy Notice to each patient, both existing and new. If the patient refuses to sign the notice, this practice is not obligated to accept you as a patient for assessment or treatment.