HERITAGE PROVIDER NETWORK, INC.
NOTICE OF PRIVACY PRACTICES – Effective Date: April 14, 2003
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Your Health
Information Rights - Although your health record is the physical property of
the healthcare practitioner or facility that compiled it, the information
belongs to you. You have the right to:
·
Request a restriction on certain uses and disclosures of your
information, however, we are not required to agree to your request for
restrictions.
·
Inspect and obtain a paper copy of your health records, except in limited
circumstances upon written request. A fee will be charged to copy your
record. If you are denied access to your health record for certain reasons, we
will tell you why and what your rights are to challenge that denial.
·
Amend your health record. Your
request must be in writing and state a reason. If we deny your request, we will
tell you why and what your rights are to challenge that denial. Even if we
accept your request, we will not delete any information already in our records.
You have the right to add an addendum (up to 250 words) to your health record.
·
Obtain an accounting of disclosures of your health information for
purpose other than treatment, payment or health care operations, disclosures to
you or authorized by you, incidental disclosures and certain other excluded
disclosures. Your request must be in writing.
·
Request confidential communications of your health information by
alternative means or at alternative locations
·
Revoke authorization to use or disclose health information except
to the extent that action has already been taken
Our
Responsibilities - This organization is required to:
·
maintain the privacy of your health information
·
provide you with a notice as to our legal duties and privacy practices
with respect to information we collect and maintain about you
·
abide by the terms of this notice currently in effect
·
notify you if we are unable to agree to a requested restriction
·
accommodate reasonable requests you may have to communicate health
information confidentially by alternative means or at alternative locations.
Contact Customer Service at 1-888-802-6538 to make this request.
·
not use or disclose your health information without your authorization,
except as described in this notice
For example: Information
obtained by a nurse, physician, or other member of your healthcare team will be
recorded in your record. Your physician will document in your record his or her
expectations. We may disclose your
health information to ancillary or specialty care services that may be
requested by your physician for treatment.
Those providers will record their care in their records and copy your
physician on their observations. In
that way, you will be provided treatment and your physician will know how you
are responding to treatment.
·
We
will use and disclose your health information for payment/encounter data.
For
example: A bill may be sent to you or a third party payer or HMO. The
information on or accompanying the bill may include information that identifies
you, as well as your diagnosis, procedures and supplies used and your treatment
for which payment is requested. We may
also disclose your health information for one of your other health care
providers to submit requests for payment.
·
We
will use and disclose your health information for our health care operations.
For
example: Members of the medical
staff and the risk or quality improvement team of this practice may use
information in your health record to assess the care and outcomes in your case.
This information will then be used in an effort to continually improve the
quality and effectiveness of the healthcare services we provide.
·
We
will use and disclose your health information for health care operations of
others.
For example: We may disclose your health information
to other health care providers or payors for their health
care operations
only if they already have a relationship with you and the purpose is for
quality assurance activities, peer review activities, detecting fraud, or other
limited purposes.
EXAMPLES:
Involvement in your care:
We may disclose
information to individuals involved in your care or to individuals who pay or
help pay for your care.
Abuse, neglect or domestic violence: We may disclose information for
reporting abuse, neglect or domestic violence to a government authority,
including a social service or protective services agency as authorized by law.
Health oversight activities: We may disclose health information to a
health oversight agency for oversight activities authorized by law.
Judicial and administrative proceedings: We may disclose health information in the
course of any judicial or administrative proceeding.
Serious threat to health or safety: We may disclose health information to
prevent a serious threat to the health or safety of another.
Specialized government functions: We may disclose health information
required by command authorities for military and Veterans.
National Security and intelligence
activities: We may
disclose health information for National Security and intelligence activities.
Genetic Testing Information: If we keep genetic testing information
about you, we will release that information only to the state departments that
monitor our work or if required by law to release that information. Otherwise, we will give out this information
only if you give us your permission in writing.
Communicable Disease Information: If you have a communicable disease, such
as HIV/AIDS, we will provide that information to your health care provider, to
providers engaged in organ procurement, or if required by law. For all other purposes, we will give out this
information only with your permission.
Research: We may disclose 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 health information.
Funeral Directors:
We may disclose health
information to funeral directors consistent with applicable law to carry out
their duties.
Patient Education: We may contact you to provide
appointment reminder or information about treatment alternatives or other
health-related benefits and services that may be of interest to you.
Workers Compensation/Third Party
Liability: We may disclose health information to the extent authorized
by and to the extent necessary to comply with laws relating to workers
compensation or third-party payers or other similar programs established by
law.
Public Health:
As required by law, we
may disclose your health information to public health or legal authorities
charged with preventing or controlling disease, injury, or disability.
Correctional Institution: Should you be an inmate of a
correctional institution, we may disclose to the institution or agents thereof
health information necessary for your health and the health safety of other
individuals.
Law Enforcement:
We may disclose health
information for law enforcement purposes as required by law.
Source of Information: We may collect information about you
from you as well as others, such as personal representatives, family members,
and medical providers.
Types of Information and Methods of
Collection: We will
collect information about you, your medical condition and needs from physicians
and other healthcare providers, including diagnoses, test results, and any
other information contained in your medical records. We will do this by
requesting copies of records and communicating with the providers.
We reserve the right to change our practices and to make the new
provisions effective for all protected health information we maintain. Should
our information practices change, we will post those changes at our offices.
For More Information, Report a Problem,
or exercise your rights –
You may contact:
Customer Service at 1-888-802-6538. There will be no retaliation for filing a
complaint. You may also contact the
Secretary of the Department of Health and Human Services, Office of Civil
Rights, San Francisco Office, U.S. Department of Education, Old Federal
Building, 50 United Nations, San Francisco, CA, 94102-4102.
HERITAGE PROVIDER NETWORK, INC.
NOTICE OF PRIVACY PRACTICES – Effective Date: April 14, 2003
After you have read
the Notice of Privacy Practices, please sign and return this page only to:
Heritage Provider
Network, Inc.
Customer Service
4570 California
Avenue
Bakersfield, CA
93309
I acknowledge that
I have received this Notice of Privacy Practices
&127; Patient &127; Responsible Party
Signature Date