http://www.urologyportcharlotte.com/hipaa-privacy-notice/HIPAA Privacy Notice
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.
Who We Are
This Notice describes the privacy practices of your physician’s medical billing company only. For your physician’s Notice of Privacy Practices, you will need to contact them directly.
Our Privacy Obligations
We are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to your PHI. When we use or disclose your PHI, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures.
Uses and Disclosures for Jens Carlsen, DO Urology. We may use and disclose PHI, but not your “Highly Confidential Information” (defined below), in order to treat you, obtain payment for equipment and services provided to you, and conduct our “healthcare operations” as detailed below.
Payment. We may use and disclose your PHI to obtain payment for equipment and services we provide to you – for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your healthcare (your “Payor”) to verify that your Payor will pay for healthcare.
Disclosure to Relatives, Close Friends, and Other Caregivers. We may use or disclose your PHI to a family member, other relative, a close personal friend, or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure. If you are not present, or if the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or close personal friend, we would disclose only information that we believe is directly relevant to the person’s involvement with your healthcare or payment related to your healthcare. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition, or death.
Public Health Activities. We may disclose your PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products or services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
Victims of Abuse, Neglect, or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect, or domestic violence, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.
Health Oversight Activities. We may disclose your PHI to a health oversight agency that oversees the healthcare system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful purpose.
Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
Decedents. We may disclose your PHI to a coroner or medical examiner as authorized by law.
Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ, eye, or tissue procurement, banking, or transplantation.
Research. We may use or disclose your PHI without your consent or authorization if an Institutional Review Board or Privacy Board approves a waiver of authorization for disclosure.
Health or Safety. We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
Specialized Government Functions. We may use or disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
Workers’ Compensation. We may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.
As Required by Law. We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.
Uses and Disclosures Requiring Your Written Authorization
Use or Disclosure with Your Authorization. For any purpose other than the ones described above, we only may use or disclose your PHI when you grant us your written authorization (“Your Authorization”). For instance, you will need to execute an authorization before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
Marketing. We must also obtain your written authorization (“Your Marketing Authorization”) prior to using your PHI to send you any marketing materials. In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers, or care settings without Your Marketing Authorization.
Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”). We will comply with such special privacy protections which may cover the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment, and referral; (4) is about HIV/AIDS testing, diagnosis, or treatment; (5) is about venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult with a disability; (9) is about sexual assault; or (10) is about adoption.
Your Rights Regarding Your Protected Health Information
For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact us at (800) 933-5190. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, we will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.
Right to Request Restrictions. You may request restrictions on our use and disclosure of your PHI: (1) for treatment, payment, and healthcare operations; (2) to individuals (such as a family member, other relative, close personal friend, or any other person identified by you) involved with your care or with payment related to your care; or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for restrictions carefully, we are not required to agree to a requested restriction. If you wish to request restrictions, please submit a written request to us.
Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
Right to Revoke Your Authorization. You may revoke your Authorization, your Marketing Authorization, or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to us.
Right to Inspect and Copy Your Health Information. You may request access to your billing records maintained by us in order to inspect and request copies of your records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please submit a written request to us. Please be reminded that our office does not maintain your medical file, and any information we relay to you will be related to billing records only. If you want a copy of your medical records, you will need to contact your physician.
Right to Amend Your Records. You have the right to request that we amend PHI maintained in your billing records. If you desire to amend your records, please send a written request for the amendment, including the reason for the amendment, to us. We will comply with your request unless we believe that the information that would be amended is accurate and complete, or other special circumstances apply.
Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request, provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.
Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
Effective Date and Duration of This Notice
Effective Date. This Notice is effective as of 3/15/2015.
Right to Change Terms of This Notice. We reserve the right to, meaning we may, change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice on our Internet site. You also may obtain any new notice by contacting us.