Effective Date: September 23, 2013
Princeton Medical Group, P.A.
NOTICE OF PRIVACY PRACTICES
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 and the HITECH (Health Information Technology for Economic and Clinical Health) OMNIBUS FINAL RULE Published in 2013.
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.
A. PRIVACY POLICIES
The Privacy Regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that certain measures be followed in maintaining the privacy of your protected health information (PHI). PHI includes individually identifiable health information such as your name, age, address, telephone number, and any other information which can be used to identify you, that relates to your past, present, or future physical or mental health or condition and related health care services. In conducting our business, we will create records regarding you and the treatment and services we provide to you that contain PHI. We are required by law to maintain the privacy of PHI, provide you with this notice of our legal duties and privacy practices that we maintain in our practice concerning your PHI, follow the terms of the Notice Of Privacy Practices that is currently in effect, and inform you of any changes that we make to the Notice of Privacy Practices.
The terms of this Notice of Privacy Practices apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this Notice will be effective for all of your records that our practice has created or maintained in the past and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice of Privacy Practices in our offices in a visible location at all times, and will make copies of the Notice available for you to take with you. You may request a copy of our most current Notice at any time by contacting our Privacy Officer or asking for a copy at your next appointment.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Privacy Officer, Princeton Medical Group, P.A., 419 North Harrison Street, Suite 203, Princeton, New Jersey 08540, (609) 924-9300
B. ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE
You will be asked to provide a signed acknowledgement of receipt of this Notice of Privacy Practices. Our intent is to inform you about the possible uses and disclosures of your PHI and your privacy rights relating to your PHI. We will not condition our delivery of health care services to you upon your signing of the acknowledgement. Even if you decline to sign the acknowledgement, we will continue to treat you and will use and disclose your PHI relating to your treatment, payment for health care treatment and other services rendered to you, and health care operations relating to our practice.
C. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI)
The following categories describe several of the different ways in which we may use and disclose your PHI. Neither the categories nor the examples described therein are exhaustive. We may also use and disclose your PHI as otherwise required or authorized by state and federal laws, rules and regulations.
1. Treatment. Our practice may use your PHI to provide, coordinate, or manage your health care and related services within our practice and with third parties. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment.
2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for health care treatment and services that you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We may also use and disclose your PHI to bill you directly or obtain payment from third parties such as family members, who may be responsible for your health care costs.
3. Health Care Operations. Our practice may use and disclose your PHI to conduct our business activities with respect to the provision of health care and related services. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you receive from us, or to conduct cost-management and business planning activities for our practice. We may also disclose your PHI to third party “business associates” who perform or assist in the performance of various activities on our behalf. These business associates will also be required to protect your PHI.
4. Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.
5. Treatment Options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.
6. Health-Related Benefits and Services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.
7. Release of Information to Family/Friends. Unless you provide us a prior written objection, our practice may release your PHI to family members, close friends, or any other person you identify who is involved in your health care or who assists in taking care of you. We may also use or disclose your PHI to notify or assist in notifying family members, personal representative, or any other person who is responsible for your health care, of your location, general condition, or death. In addition, we may use or disclose your PHI to an authorized governmental or private entity to assist in disaster relief efforts and coordinate uses and disclosures to family or other individuals involved in your health care.
8. Disclosures Required By Law. Our practice will use and disclose your PHI when we are required to do so by federal, state and local law.
9. Marketing Activities. We may contact you as part of our marketing activities, as permitted by law.
D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your protected health information:
1. Public Health Risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for purposes such as:
- Maintaining vital records, such as births and deaths;
- Reporting child abuse or neglect;
- Preventing or controlling disease, injury or disability;
- Notifying a person regarding a potential exposure to a communicable disease;
- Notifying a person regarding a potential risk for spreading or contracting a disease or condition;
- Reporting reactions to drugs or problems with products or devices;
- Notifying individuals if a product or device they may be using has been recalled;
- Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or
neglect of an adult patient (including domestic violence); however, we will only disclose this
information if the patient agrees or we are required or authorized by law to disclose this
- Notifying your employer under limited circumstances related primarily to workplace injury or
illness or medical surveillance.
2. Health Oversight Activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have received satisfactory assurances, in accordance with HIPAA, that reasonable efforts have been made to inform you of the request or to obtain a court or administrative order protecting the information the party has requested.
4. Law Enforcement. We may release PHI if asked to do so by a law enforcement official:
- Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement;
- Concerning a death we believe has resulted from criminal conduct;
- Regarding criminal conduct at our offices;
- In response to a warrant, summons, court order, subpoena or similar legal process;
- To identify/locate a suspect, material witness, fugitive or missing person; and
- In an emergency, to report a crime (including the location or victim(s)
of the crime, or the description, identity or location of the person who might have committed the
5. Deceased Patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual to identify the cause of death, or to perform other activities authorized by law. If necessary, we also may release PHI to funeral directors as authorized by law.
6. Organ and Tissue Donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
7. Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances when authorized by law. For example, we may disclose your PHI to researchers, if 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 PHI. We will obtain your written authorization to use your PHI for research purposes whenever we are legally required to do so.
8. Serious Threats to Health or Safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make legally authorized disclosures to a person or organization able to help prevent the threat.
9. Military. If you are a member of U.S. or foreign military forces (including veterans), our practice may disclose your PHI as required by the appropriate authorities. For example, we may disclose your PHI for determination by the United States Department of Veterans Affairs of your eligibility for benefits or to military command authorities for determination of your fitness for duty.
10. National Security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations of matters of national security.
11. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of law enforcement officials. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.
12. Workers’ Compensation. Our practice may release your PHI to comply with workers’ compensation and similar programs.
13. Other Uses. Other uses and disclosures will be made only with your written authorization and you may revoke the authorization except to the extent Princeton Medical Group has taken action in reliance on such.
Note: HIV-related information, genetic information, alcohol and/or substance abuse records, mental health records and other specially Protected Health Information may enjoy certain special confidentiality protections under applicable state and federal law. Any disclosures of these types of records will be subject to these special protections.
E. YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding the PHI that we maintain about you:
1. Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Privacy Officer, Princeton Medical Group, P.A. 419 North Harrison Street, Suite 203, Princeton, New Jersey 08540, (609) 924-9300 ext. 3302 specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions: You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. You may revoke a previously agreed upon restriction, at any time, in writing. We may also terminate our agreement to a previously agreed upon restriction, at any time, in writing. However, our termination of such an agreement will only apply to PHI created or received after we have informed you of the termination. In order to request a restriction in our use or disclosure of your PHI, contact the Privacy Officer, Princeton Medical Group, P.A., 419 North Harrison Street, Suite 203, Princeton, New Jersey 08540, (609) 924-9300 ext. 3302. A request form will be mailed to you for your completion and return to the Privacy Officer; your request must be in writing.
Regarding your right to restrict disclosure to your health plan where you have paid for your services out of pocket in full prior to receiving the service, at your request, we will not share information about those services with a health plan for purposes of payment or health care operations.
3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. In order to inspect and/or obtain a copy of your PHI, contact the Privacy Officer, Princeton Medical Group, P.A., 419 North Harrison Street, Suite 203, Princeton, New Jersey 08540, (609) 924-9300 ext. 3302. A request form will be mailed to you for your completion and return to the Privacy Officer; your request must be in writing. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and /or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, contact the Privacy Officer, Princeton Medical Group, P.A., 419 North Harrison Street, Suite 203, Princeton, New Jersey 08540, (609) 924-9300 ext. 3302. A request form will be mailed to you for your completion and return to the Privacy Officer; your request must be in writing. You must provide us with a reason that supports your request for amendment. Although we accept requests for amendment, we are not required to agree to the requested amendment. For Example, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures,” which is a list of certain non-routine disclosures our practice has made of your PHI for other than treatment, payment, or health care operations purposes. Use of your PHI as part of the routine patient care in our practice is not subject to an accounting of disclosures. For example, we are not required to provide an accounting of disclosures that document each time a doctor shares information with a nurse; or each time the billing department uses your PHI to file your insurance claim. In order to obtain an accounting of disclosures, contact the Privacy Officer, Princeton Medical Group, P.A., 419 North Harrison Street, Suite 203, Princeton, New Jersey 08540, (609) 924-9300 ext. 3302. A request form will be mailed to you for your completion and return to the Privacy Officer; your request must be in writing. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
6. Right to Paper Copy of This Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices, even if you agree to obtain an electronic copy of the Notice. You may request a paper copy of this Notice, at any time. To obtain a paper copy of our Notice of Privacy Practices, contact Privacy Officer, Princeton Medical Group, P.A., 419 North Harrison Street, Suite 203, Princeton, New Jersey 08540, (609) 924-9300 ext. 3302.
7. Right to File a Complaint. If you believe your privacy rights have been violated in contravention of HIPAA, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact the Privacy Officer, Princeton Medical Group, P.A., 419 North Harrison Street, Suite 203, Princeton, New Jersey 08540, (609) 924-9300 ext. 3302. A complaint form will be mailed to you for your completion and return to the Privacy Officer; your complaint must be submitted in writing. You will not be retaliated against for filing a complaint.
8. Right to Obtain an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or otherwise permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the purposes described in the authorization. Please note we are by law to retain our records of the health care treatment and services that we have provided to you.
9. Health Information Exchange (HIE). If PMG joins any Health Information Exchange (HIE), you have the right to opt-out if you do not wish to allow providers involved in your health care to electronically share your health information with one another as necessary and as otherwise permitted by law. In order to opt-out, you must submit a written statement informing us of your HIE opt-out request. Upon receipt of your request, your health information will continue to be used and disclosed in accordance with this HIPAA Notice of Privacy Practices and the law, but will no longer be available electronically to otherwise authorized providers through our HIE (s).
F. CONTACT INFORMATION
Again, if you have any questions regarding this Notice or our health information privacy policies, please contact the Privacy Officer, Princeton Medical Group, P.A., 419 North Harrison Street, Suite 203, Princeton, New Jersey 08540, (609) 924-9300 ext. 3302.