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.
The Pain Relief Center of Northern
Arizona, a division of Switzer Medical, Incorporated (SMI) respects your
privacy. We understand that your personal health information is very sensitive.
We will not disclose your information to others unless you tell us to do so, or
unless the law authorizes or requires us to do so.
The law protects the privacy of the
health information we create and obtain in providing our care and services to
you. For example, your protected health information includes your symptoms,
test results, diagnoses, treatment, health information from other providers,
and billing and payment information relating to these services. Federal and
state law allows us to use and disclose your protected health information for
purposes of treatment and health care operations.
Examples of Use and Disclosures of
Protected Health Information for Treatment, Payment, and Health Operations
For
treatment:
·
Information obtained by a medical assistant, nurse, physician, or
other member of our health care team will be recorded in your medical record
and used to help decide what care may be right for you.
·
We may also provide information to others providing you care. This
will help them stay informed about your care.
For
payment:
·
We request payment from your health insurance plan. Health plans
need information from us about your medical care. Information provided to
health plans may include your diagnoses, procedures performed, or recommended
care.
For health
care operations:
·
We use your medical records to assess quality and improve
services.
·
We may use and disclose medical records to review the
qualifications and performance of our health care providers and to train our
staff.
·
We may contact you, your family or leave messages on your home
answering machine to remind you about appointments or to call our office.
·
We may contact you to give you information about treatment
alternatives or other health-related benefits and services.
·
We may contact you to raise funds.
·
We may use and disclose your information to conduct or arrange for
services, including:
·
medical quality review by your health plan;
·
accounting, legal, risk management, and insurance services;
·
audit functions, including fraud and abuse detection and
compliance programs.
The health and billing
records we create and store are the property of SMI. The protected health
information in it, however, generally belongs to you. You have a right to:
·
Receive, read, and ask questions about this Notice;
·
Ask us to restrict certain uses and disclosures. You must deliver
this request in writing to us. We are not required to grant the request. But we
will comply with any request granted;
·
Request and receive from us a paper copy of the most current
Notice of Privacy Practices for Protected Health Information;
·
Request that you be allowed to see and get a copy of your
protected health information. You may make this request in writing. We have a
form available for this type of request.
·
Have us review a denial of access to your health
information—except in certain circumstances;
·
You may write a statement to be placed into your medical records
if you believe information in the medical records is incorrect. It will be
included with any release of your records.
·
When you request, we will give you a list of disclosures of your
health information. The list will not include disclosures to third-party
payors. You may receive this information without charge once every 12 months.
We will notify you of the cost involved if you request this information more
than once in 12 months.
·
Ask that your health information be given to you by another means
or at another location. Please sign, date, and give us your request in writing.
·
Cancel prior authorizations to use or disclose health information
by giving us a written revocation. Your revocation does not affect information
that has already been released. It also does not affect any action taken before
we have it. Sometimes, you cannot cancel an authorization if its purpose was to
obtain insurance.
For help with these rights during normal business hours, please
contact our
Privacy Officer at
928-774-3070
We are
required to:
·
Keep your protected health information private;
·
Give you this Notice;
·
Follow the terms of this Notice.
We have the right to
change our practices regarding the protected health information we maintain. If
we make changes, we will update this Notice. You may receive the most recent
copy of this Notice by calling and asking for it or by visiting our office to
pick one up.
If you have questions,
want more information, or want to report a problem about the handling of your
protected health information, you may contact our Privacy Officer at
928-774-3070
If you believe your
privacy rights have been violated, you may discuss your concerns with any staff
member. You may also deliver a written complaint to our Privacy Officer at our
office. You may also file a complaint with the U.S. Secretary of Health and Human
Services.
We respect your right to
file a complaint with us or with the U.S. Secretary of Health and Human
Services. If you complain, we will not retaliate against you.
Notification
of Family and Others
·
Unless you
object in writing, we may release health information about you to a friend or
family member who is involved in your medical care. We may also give
information to someone who helps pay for your care. In addition, we may
disclose health information about you to assist in disaster relief efforts.
You have the right to object to this use
or disclosure of your information. If you object, we will not use or disclose
it.
·
With
Medical Researchers—if
the research has been approved and has policies to protect the privacy of your
health information. We may also share information with medical researchers
preparing to conduct a research project.
·
To
Funeral Directors/Coroners
consistent with applicable law to allow them to carry out their duties.
·
To Organ
Procurement Organizations (tissue donation and transplant) or persons who obtain, store, or
transplant organs.
·
To the
Food and Drug Administration (FDA) relating to problems with food, supplements, and products.
·
To
Comply With Workers’ Compensation Laws—if you make a workers’ compensation claim.
·
For
Public Health and Safety Purposes as Allowed or Required by Law:
·
to prevent
or reduce a serious, immediate threat to the health or safety of a person or
the public.
·
to public
health or legal authorities
·
to protect
public health and safety
·
to prevent
or control disease, injury, or disability
·
to report
vital statistics such as births or deaths.
·
To
Report Suspected Abuse or Neglect to public authorities.
·
To
Correctional Institutions
if you are in jail or prison, as necessary for your health and the health and
safety of others.
·
For Law
Enforcement Purposes
such as when we receive a subpoena, court order, or other legal process, or you
are the victim of a crime.
·
For
Health and Safety Oversight Activities. For example, we may share health information with the
Department of Health.
·
For
Disaster Relief Purposes.
For example, we may share health information with disaster relief agencies to
assist in notification of your condition to family or others.
·
For
Work-Related Conditions That Could Affect Employee Health. For example, an employer may ask us to
assess health risks on a job site.
·
To the
Military Authorities of U.S. and Foreign Military Personnel. For example, the law may require us to
provide information necessary to a military mission.
·
In the
Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court
order.
·
For
Specialized Government Functions. For example, we may share information for national security
purposes.
·
Uses and
disclosures not in this Notice will be made only as allowed or required by law
or with your written authorization.
·
We have a
Web site that provides information about us. For your benefit, this Notice is
on the Web site at this address: www.nosuffering.com/privacy.
April 14, 2003