Practice Privacy Statement

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.

I. This is a formal notification, as required by CMS (Centers for Medicare and Medicaid Services) concerning the privacy policy of this practice. It is important that all patients and staff understand the importance of guarding patient information.

II. This practice has a legal obligation to maintain all medical records and information in the strictest of confidence as required by law. What this means to the patient is that we must safeguard patient information. This means we cannot release information to others without your written consent, including conversations, test results and other information that may be of a confidential nature. Patient information about health care is identified as "PHI" or protected health information.

This change in policy requires that you, the patient, identify and clarify at the time of registration or re-registration with this practice who we can talk to, how we can leave information on your behalf, and the process for ongoing continuity of your medical care. You can change this information at any time with either written notification or verbal notification, followed up in writing. Changes can only impact the care or information from that point in time forward.

III. Your protected health information (PHI) is an intricate part of your medical care, and can be used or disclosed with your written consent as follows:

• For your treatment in this practice and other locations under the physicians immediate care. This may include any referral for services such as diagnostic cardiac imaging, prescription information, hospital procedures, or other diagnostic testing or treatment related to your condition or medical care needs. This may also include conversations with other physicians.
  
• For obtaining payment for treatment with your identified insurance or health coverage program. This would include any documentation related to this process, which may include history forms, progress notes or operative notes. This would include eligibility verification, prior authorization and claim submission.
  
• For operations of this practice, such as enrolling with insurance programs, hospital privileges, accounting and compliance with federal and state laws and regulations.
  
• Consent is not required for emergency care and treatment. An emergency is identified as a medical condition that in the judgment of the physician or medical entity required immediate and full information for care on your behalf.

Certain disclosures can be made without your consent, and they are as follows:

• Disclosure required by the government or law enforcement agencies. Specific areas that require release include gun shot wounds, domestic violence, and victims of abuse or neglect.
  
• Information used for public health purposes, medical examiners or related to a person’s death or for the health department for disease tracking.
  
• Information used for health care oversight, such as a site review by an insurance program.

IV. Yours rights with respect to you protected health information.

• The right to request limits on the uses and disclosure at registration or any time during your care.
• The right to choose how we send this information to you, including an alternate address.
• The right to see and obtain copies of this information, but there may be copy and postage fees.
• The right to correct and update your file through an amendment process, if appropriate.
  

V. This practice reserves the right to modify or change this Privacy Statement and process at any time. Revision to the Notice will be available upon request by contacting the office. The changes will be effective retroactively to the initial date of the Privacy Notice. An updated Privacy Notice will be posted in the office within 60 days of the revision.

VI. If you have a concern or complaint about how your protected health information is being used, from this time forward you should first contact our office to see if we can resolve your concerns or you may contact the Office of Civil Rights or the Ohio Medicare Carrier, GBA Palmetto.

• Contact the office manager and complete a complaint form for review and discussion.
• If you are not satisfied with this response, you may report the practice to:

Office of Civil Rights
Regional Manager
Department of Health & Human Services
233 N. Michigan Avenue, Suite 240
Chicago, Illinois 60601

Or the local Medicare Part B Intermediary

GBA Palmetto
Part B Operations –— HIPAA Compliance Concern
PO Box 182957
Columbus, Ohio 43218