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.
INTRODUCTION:
Protected health information is information about you, including demographic information,
that may identify you and that relates to your past, present or future physical or mental health
or condition and related health care services. We are committed to treating and using protected
health information (PHI) about you responsibly. This Notice of Privacy Practices describes how
we may use and disclose your protected health information (PHI) to carry out treatment, payment
or health care operations (TPO) and for other purposes that are permitted or required by law. It
also describes your rights to access and control your protected health information.
OUR LEGAL DUTY:
Federal and state law requires us to maintain the privacy of your health information. That law also
requires us to give you this notice about our privacy practices, our legal duties, and your rights
concerning your health information. We must follow the privacy practices we describe in this notice
while it is in effect. This notice takes effect January 1, 2009, and will remain in effect until we replace it.
It applies to all (PHI) Protected Health Information as defined by federal regulation.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided
such applicable law permits the changes. We reserve the right to make the changes in our privacy
practices and the new terms of our notice effective for all health information that we maintain,
including health information we created or received before we made the changes. Before we make a
significant change in our privacy practices, we will change this notice and make the new notice
available upon request.
You may request a copy of our notice at any time. For more information about our privacy practices,
or for additional copies of this notice, please contact us using the information listed at the end of this
notice.
USES AND DISCLOSURES OF HEALTH INFORMATION:
Your protected health information may be used and disclosed by your physician, our office staff and
others outside of our office that are involved in your care and treatment for the purpose of providing
health care services to you, to pay your health care bills, to support the operations of the physician's
practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or
manage your health care and any related services. This includes the coordination or management
of your health care with a third party. For example, your protected health information, as necessary,
to a home health agency that provides care for you. For example, your protected health information
may be provided to a physician to whom you have been referred to ensure that the physician has the
necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health
care services. For example, obtaining approval for a hospital stay may require that your relevant
protected health information be disclosed to the health plan to obtain approval for the hospital
admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in
order to support the business activities of your physician's practice. These activities include, but
are not limited to, qualify assessment activities, employee review activities, training of medical
assistants, licensing, and conducting or arranging for other business activities. For example, we may
disclose your protected health information to medical school students that see patients at our office.
In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your
name and indicate your physician. We may also call you by name in the waiting room when your
physician is ready to see you. We may use or disclose your protected health information, as necessary,
to contact you to remind you of your appointment like voicemail messages, postcards or letters.
To your Family and Friends: We may disclose your health information to a family member, friend or
other person to the extent necessary to help with your health care or with payment for your health care.
Before we disclose your health information to these people, we will provide you with an opportunity
to object to our use or disclosure. If you are not present, or in the event of your incapacity or an
emergency, we will disclose your medical information based on our professional judgment of whether
the disclosure would be in your best interest. We may use our professional judgment and our
experience with common practice to make reasonable references of your best interest in allowing a
person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health
information. We may use or disclose information about you to notify or assist in notifying a person
involved in your care, of your location and general condition.
Disclosure without authorization: We may disclose your protected health information in the following
situations without your authorization. These situations include: as Required By Law, Public Health
issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and
Drug Administrative requirements: Legal Proceedings: Law Enforcement: Coroners: Funeral Directors:
and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers'
Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures
to you and when required by the Secretary of the Department of Health and Human Services to
investigate or determine our compliance with the requirements of Section 164.500. We may use or
disclose your protected health information to public or private entity authorized by law or by its
charter to assist in disaster relief efforts.
Other Permitted and Required Uses and Disclosures: Willl be made only with your consent,
authorization or opportunity to object unless required by law.
ON YOUR AUTHORIZATION:
You may give us written authorization to use your health information or to disclose it to anyone for
any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation
will not affect any uses or disclosures permitted by your authorization while it was in effect. Unless
you give us a written authorization, we cannot use or disclose your health information for any reason
except those described in this notice.
YOUR RIGHTS:
Following is a statement of your rights with respect to your protected health information.
Access: You have the right to inspect and copy your protected health information.
Under federal law, however, you may not inspect or copy the following records, psychotherapy notes;
information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action
or proceeding, and protected health information that is subject to law that prohibits access to
protected health information. You may request that we provide copies in a format other than
photocopies. We will use the format you request unless we cannot practicably do so. You must make
a request in writing to obtain access to your health information. You may request access by sending
us a letter to the address at the end of this notice. If you request copies, we will charge you a
reasonable cost-based fee that may include labor, copying costs, and postage. If you request an
alternative format, we will charge a cost-based fee for providing your health information in that format.
If you prefer, we may-but are not required to-prepare a summary or an explanation of your health
information for a fee. Contact us using the information listed at the end of this notice for more
information about fees.
Disclosure Accounting: You have the right to receive an accounting of certain disclosures we have
made, if any, at your protected health information.
You have the right to receive a list of instances in which we or our business associates disclosed
your health information over the last 6 years. That list will not include
disclosures for treatment, payment, healthcare operations, as authorized by you, and for certain other
activities. If you request this accounting more than once in a 12-month period, we may charge you a
reasonable, cost-based fee for responding to these additional requests. Contact us using the
information listed at the end of this notice for more information about fees.
Restriction: You have the right to request a restriction of your protected health information.
Any agreement we may make to a request for additional restrictions must be in writing signed by
a person authorized to make such an agreement on our behalf. Your request is not binding unless
our agreement is in writing. This means you may ask us not to use or disclose any part of your
protected health information for the purposes of treatment, payment or healthcare operation. You may
also request that any part of your protected health information may not be disclosed to family
members or friends who may be involved in your care or for notification purposes as describes in
this Notice of Privacy Practices. Your request must state the specific restriction requested and to
whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If physician believes it
is in your best interest to permit use and disclosure of your protected health information, your
protected health information will not be restricted. You then have the right to use another Healthcare
Professional. But if we do, will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request to receive confidential communications
from us by alternative means or at an alternative location. You gave the right to obtain a paper copy
of this notice from us.
Upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You must
make your request in writing. You must specify in your request the alternative means or location,
and provide satisfactory explanation how you will handle payment under the alternative means or
location you request.
Amendment: You have the right to have your physician amend your protected health information.
Your request must be in writing, and it must explain why we should amend the information. We may
deny your request under certain circumstances. If we deny your request for amendment, you have
the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement
and will provide you with a copy of any such rebuttal.
QUESTIONS AND COMPLAINTS:
If you want more information about our Privacy Practices or have concerns, please contact us and
ask to speak with our HIPAA compliance officer in person or by phone at (563) 583-9300,
by fax (563) 589-2555. You may 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 upon request. We support your right to the privacy of your health
information. We will not retaliate in any way if you choose to file a complaint with us or with the
U.S. Department of Health and Human Services.
HIPAA Notice of Privacy Practices
Dubuque Family Practice, 320 N. Grandview, Suite D, Dubuque, IA 563-589-9300
