AVALA Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AS WELL AS HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact our facility Privacy Officer at email@example.com.
This Notice of Privacy Practices explains how we may use and disclose your Protected Health Information to carry out treatment, payment and health care operations as well as for other purposes that are permitted or required by law. This notice also explains your rights with respect to your Protected Health Information. Protected Health Information is medical information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health and related health care services.
- Uses and Disclosures of Protected Health Information for Treatment, Payment, and Health Care Operations.
The following are examples of the types of uses and disclosures of your Protected Health Information that Avala is permitted by the HIPAA Privacy Regulations to make for the purposes of treatment, payment, and health care operations. These examples are not meant to be exhaustive; they are only examples of the types of uses and disclosures that may be made by our office.
Treatment: We may 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 such as another physician’s office. For example, we may disclose your Protected Health Information, as necessary, to a home health agency that provides care to you. We may also disclose your Protected Health Information to other physicians who are treating you. Your Protected Health Information also may be provided to a physician whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
In addition, we may disclose your Protected Health Information to another health care provider (e.g., a specialist or laboratory) who, at the request of your physician, has been retained to provide assistance with your treatment.
Payment: We may use your Protected Health Information, as necessary, to obtain and ensure payment for health care services provided to you, as your health insurance provider may engage in the following activities before it approves or pays for the health care services we recommend for you: determining your eligibility or coverage for insurance benefits, reviewing the services provided or recommended to you for medical necessity, and undertaking utilization review activities. For instance, Protected Health Information may be disclosed to a health insurance provider so that we may obtain approval for a patient’s hospital admission.
Health Care Operations: We may use or disclose your Protected Health Information in order to support the business activities of our practice. These activities includ3e, but are limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. To name a few examples, we may disclose your Protected health Information to medical students who treat patients at our hospital; we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician; and we may call your name in the waiting room when your physician is ready to see you.
- Other Permitted and Required Uses and Disclosures of Your Protected Health Information That May Be Made Without Your Authorization
The following are descriptions of scenarios under which the Company is either permitted or required by the HIPAA Privacy Regulations to use or disclose your Protected Health Information without your authorization.
Required by Law: We may use or disclose your Protected Health Information to the extent that such use or disclosure is required by law. In such event, the use or disclosure of your Protected Health Information will be made only in compliance with the maw and will be limited to the relevant requirements of the law. Further, as required by law, you will be notified of any such use or disclosure.
Public Health: We may disclose your Protected Health Information to a public health authority that is permitted by law to collect or receive such information for the purpose of controlling disease, injury or disability. We may also disclose your Protected Health Information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Communicable Diseases: We may disclose your Protected Health Information, if authorized by law, to a person who has or may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose your Protected Health Information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights law.
Abuse or Neglect: We may disclose your Protected Health Information to a public health authority that is authorized by law to receive reports of child abuse or neglect. Further, we may disclose your Protected Health Information if we believe that you have been a victim of abuse, neglect or domestic violence to the government entity or agency authorized to receive and act on such information. In such event, disclosure would be consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your Protected Health Information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, and biologic product deviations; track products; enable product recalls; make repairs or replacements to such products; or conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose your Protected Health Information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and, in certain conditions, in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may disclose your Protected Health Information, provided applicable legal requirements are met, for certain law enforcement purposes. These law enforcement purposes include (1) certain legal processes required by law, (2) limited information requests for patient identification and location purposes, (3) limited information requests pertaining to victims of a crime, (4) circumstances in which it is suspected that death has occurred as a result of criminal conduct, (5) circumstances in which a crime occurred on the premises of our medical facilities, and (6) circumstances in which there was a emergency and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose your Protected Health Information to a coroner or medical examiner for identification purposes, determining one’s cause of death, or to enable the coroner or medical examiner to perform such other duties as authorized by law. Further, we may also disclose your Protected Health Information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his or her duties; we may disclose your Protected Health Information in reasonable anticipation of your death; and we may disclose such information for cadaveric organ, eye or tissue donation purposes.
Research: We may disclose your Protected Health Information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your Protected Health Information.
Criminal Activity: We may disclosure your Protected Health Information, in accordance with applicable state and federal laws, if we believe that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public. We may also disclose your Protected Health Information if law enforcement authorities need such information to identify or apprehend an individual.
Military Activity and National Security: We may disclose your Protected Health Information if you are or were a member of the Armed Forces, when appropriate conditions apply, (1) for activities deemed necessary by appropriate military command authorities, (2) to enable the Department of Veterans Affairs to determine eligibility for benefits, or (3) to a foreign military authority if you are a member of that foreign military service. We may also disclose your Protected Health Information to authorized federal officials conducting national security and intelligence activities, including the provision of protective services to the President, or others legally authorized.
Workers Compensation: We may disclose your Protected Health Information to comply with workers’ compensation laws and other similar programs.
Inmates: We may use or disclose your Protected Health Information if you are an inmate of a correctional facility and your physician has created or received your Protected Health Information in the course of providing care to you.
- Other Uses and Disclosures of Your Protected Health Information
We may also use and disclose your Protected Health Information in the following ways:
Business Associates: We may share your Protected Health Information with third party business associates that perform certain activities for our medical practice (e.g., billing and transcription services). If such an arrangement between our office and a business associate involves the use or disclosure of your Protected Health Information, the arrangement will be governed by a written contract that contains terms protecting the privacy of your Protected Health Information.
Health Information Exchange: We may share your information for treatment, payment, and healthcare operations purposes through health information exchange in which we participate in order for participants to efficiently access and use your pertinent medical information necessary for treatment and other lawful purposes.
Appointment Reminders and Other Information: We may use your Protected Health Information to provide appointment reminders or information about treatment alternatives or health-related benefits and services that may be of interest to you. For example, we may send you a newsletter about our medical practice or the medical services that we offer to patients.
Photographs: We may use photography or other means of image recording to capture pictures and imaging in an effort to offer better patient identification for work force members, security purposes, and billing procedures.
- Other Uses and Disclosures of Protected Health Information That May Be Made With Your Authorization or after an opportunity for you to Object
We may use and disclose your Protected Health Information in the following instances. In such instances, you will have the opportunity to either agree or object to the use or disclosure of all, or a part, of your Protected Health Information. If you are not present to either agree or object to the use or disclosure of the Protected Health Information, then your physician may, using professional judgement, determine whether the disclosure is in your best interest. In such case, only the Protected Health Information that is relevant to your health care will be disclosed. We will not use or disclose your Protected Health Information for fundraising purposes. Additionally, we will seek your approval in limited marketing activities.
Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care, If you are unable to agree or object to such disclosure, we may disclose such information as necessary if we determine, using our professional judgement, that doing so is in your best interest. We may also use or disclose Protected Health Information to notify, or assist in the notification of, a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Further, we may use or disclose your Protected Health Information to an authorized public or private entity to assist in disaster relief efforts and to coordinate use and disclosure to family or other individuals involved in your health care.
Emergencies: We may use or disclose your Protected Health Information in an emergency treatment situation.
- Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization
Any other uses and disclosures of you Protected Health Information, including uses and disclosures of psychotherapy notes, will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke such authorization, in writing, at any time, except to the extent that our hospital has acted in reliance on the use or disclosure indicated in the authorization.
- Your Rights With Respect to Your Protected Health Information
The following are statements of your rights with respect to your Protected Health Information and a brief description of how you may exercise these rights.
Your Right to Request Restrictions: You have the right to request that the disclosure of your Protected Health Information be limited. This means you may ask us not to use or disclose any part of you Protected Health Information for the purpose of treatment, payment or healthcare operations. You may also request that certain aspects of your Protected Health Information not be disclosed for notification purposes as described in the Notice of Privacy Practices or to family members or friends who may be involved in your healthcare. Your request must state the specific restriction requested and to whom you want the restriction to apply. We recognize the importance of patient privacy and upon request or due to necessity we will provide an alias name for you.
You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care. To request a restriction, you must make your request in writing. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protective Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out of pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Your physician is not required to agree to any restriction that you may request. If your physician does agree to any restriction that you may request. If your physician does agree to the requested restriction, however, we may not use or disclose your Protected Health Information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, you should discuss any restriction you are considering requesting with your physician. If you decide to request a restriction, you may do so by notifying in writing our Privacy Officer.
Your Right to Inspect and Copy Your PHI: You have the right to inspect and copy your Protected Health Information. Therefore, you may inspect and obtain a copy from us of designated records sets containing your Protected Health Information as long as we maintain this information. A designated record set contains medical, billing and any other records that your physician or our medical practice uses to make decisions about you.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes if denied by physician; information complied in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding; and certain records that are subject to law prohibiting access to Protected Health Information. Depending on the circumstances, a decision denying you access to such records may be reviewable. Please contact our Privacy Officer if you have questions about accessing your medical records.
If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with producing the requested record.
Your Right to amend Your PHI: You may have the right to have your physician amend your Protected Health Information. This means you may request an amendment of a designated record set containing your Protected Health Information as long as we maintain this information. In certain cases, though, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with us, in which case we may prepare a rebuttal to your statement, which we will provide to you. Please contact our Privacy Officer if you have any questions about amending your medical records.
Your Right to Receive an Accounting of Disclosures of Your PHI: You have the right to receive an accounting of certain disclosures we have made, if any, of your Protected Health Information occurring after April 14, 2002, although you may request a shorter timeframe. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in the Notice of Privacy Practices. This right excludes disclosures we may have made to you, to a facility directly, to family members or friends involved in your healthcare, or for notifications purposes. The right to receive such information is subject to certain exceptions, restrictions and limitations.
Your Right to Obtain a Paper Copy of this Notice: You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
- Duties of the Company With Respect to Your Protected Health Information
Legal Duties: The Company is required by law to maintain the privacy of your Protected Health Information and to provide you with notice of our legal duties and privacy practices with respect to your Protected Health Information.
Revisions to this Notice of Privacy Practices: We are required to abide by the terms of the Notice of Privacy Practices is currently in effect. We reserve the right to change the provisions of this Notice of Privacy Practices. Whenever there is minimal change to this notice, we will make our best effort to provide you with a copy of the revised notice on your next visit to our offices.
You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying in writing the applicable Privacy Officer.
- Privacy Officer
Our facility Privacy Officer Charise Drouant, can be reached at (985) 801 – 6267.