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 READ IT CAREFULLY.
Our goal is to take appropriate steps to attempt to safeguard any medical or other personal information that is provided to us. We are required to: (i) maintain the privacy of medical information provided to us; (ii) provide notice of our legal duties and privacy practices; and (iii) abide by the terms of our Notice of Privacy Practices currently in effect.
WHO WILL FOLLOW THIS NOTICE
This notice describes the practices of the employees and staff of Tower Imaging, Inc.
INFORMATION COLLECTED ABOUT YOU
In the ordinary course of receiving treatment and health care services from us, you will be providing us with personal information such as:
· Your name, address and phone number
· Information relating to your medical history
· Your insurance information and coverage
· Information concerning your doctor, nurse or other medical providers
In addition, we will gather certain medical information about you and will create a record of the care provided to you. Some information also may be provided to us by other individuals or organizations that are part of your "circle of care" - such as the referring physician, your other doctors, your health plan, and close friends or family members.
HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU
We may use and disclose personal and identifiable health information about you in different ways. All of the ways in which we may use and disclose information will fall within one of the following categories, but not every use or disclosure in a category will be listed.
For Treatment. We will use health information about you to furnish services and supplies to you, in accordance with our policies and procedures. For example, we will use your medical history, such as any presence or absence of heart disease, to assess your health and perform requested diagnostic services. We may also send a report of our findings to one or more of your other physicians.
For Payment. We will use and disclose health information about you to bill for our services and to collect payment from you or your insurance company. For example, we may need to give a payor information about your current medical condition so that it will pay us for the examinations or other services that we have furnished you. We may also need to inform your payer of the tests that you are going to receive in order to obtain prior approval or to determine whether the service is covered.
For Health Care Operations. We may use and disclose information about you for the general operation of our business. For example, we sometimes arrange for accreditation organizations, auditors or other consultants to review our practice, evaluate our operations, and tell us how to improve our services. We may also call you to give you instructions about your appointment. We will use the number(s) you give us at the time you make your appointment. We may call you to conduct satisfaction surveys. Your home number will be used for the survey unless you give us other instructions.
Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment or that you should schedule an appointment.
• Lay letters for mammograms1
Treatment Alternatives. We may use and disclose your personal health information in order to tell you about or recommend possible treatment options, alternatives or health-related services that may be of interest to you.
Public Policy Uses and Disclosures. There are a number of public policy reasons why we may disclose information about you.
We may disclose health information about you when we are required to do so by federal, state, or local law.
We may disclose protected health information2 about you in connection with certain public health reporting activities. For instance, we may disclose such information to a public health authority authorized to collect or receive PHI for the purpose of preventing or controlling disease, injury or disability, or at the direction of the public health authority, to an official of a foreign government agency that is acting in collaboration with a public health authority. Public health authorities include state health departments, the Center for Disease Control, the Food and Drug Administration, the Occupational Safety and Health Administration and the Environmental Protection Agency, to name a few. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
We are also permitted to disclose protected health information to a public health authority or other government authority authorized by law to receive reports of child abuse or neglect. Additionally, we may disclose protected health information to a person subject to the Food and Drug Administration's power for the following activities; to report adverse events, product defects or problems of biological product deviations, to track products to enable product recalls, repairs or replacements, or to conduct post-marketing surveillance.
We may disclose your protected health information in situations of domestic abuse or elder abuse.
We may disclose protected health information in connection with certain health oversight activities of licensing and other agencies. Health oversight activities include audit, investigation, inspection, licensure or disciplinary actions, and civil, criminal, or administrative proceedings or actions or any other activity necessary for the oversight of 1) the health care system, 2) governmental benefit programs for which health information is relevant to determining beneficiary eligibility, 3) entities subject to governmental regulatory programs for which health information is necessary for determining compliance with program standards, or 4) entities subject to civil rights laws for which health information is necessary for determining compliance.
1 Mammogram result letters sent to the patient as required by Mammography Quality Standards Act.
2 Protected Health Information: Protected health information is individually identifiable health information which becomes protected health information when it is: (i) transmitted by electronic media; (ii) maintained in electronic media, or (iii) transmitted or maintained in any other form or medium. The final version covers paper and even verbal disclosure of individually identifiable health information.
We may disclose information in response to a warrant, subpoena, or other order of a court or administrative hearing body, and in connection with certain government investigations and law enforcement activities.
We may release personal health information to a coroner or medical examiner to identify a deceased person or determine the cause of death. We also may release personal health information to organ procurement organizations, transplant centers, and eye or tissue banks.
We may release your personal health information to workers' compensation or similar programs.
Information about you also will be disclosed when necessary to prevent a serious threat to your health and safety or the health and safety of others.
We may use or disclose certain personal health information about your condition and treatment for research purposes where an Institutional Review Board or a similar body referred to as a Privacy Board determines that your privacy interests will be adequately protected in the study. We may also use and disclose your protected health information to prepare or analyze a research protocol and for other research purposes.
If you are a member of the Armed Forces, we may release personal health information about you as required by military command authorities. We also may release personal health information about foreign military personnel to the appropriate foreign military authority.
We may disclose your protected health information for legal or administrative proceedings that involve you. We may release such information upon order of a court or administrative tribunal. We may also release protected health information in the absence of such an order and in response to a discovery to other lawful request, if efforts have been made to notify you or secure a protective order.
If you are an inmate, we may release protected health information about you to a correctional institution where you are incarcerated or to law enforcement officials.
We never market or sell your personal information.
We will not user your personal information to contact you for fundraising efforts.
Finally, we may disclose protected health information for national security and intelligence activities and for the provision of protective services to the President of the United States and other officials of foreign heads of state.
Our Business Associates. We sometimes work with outside individuals and businesses that help us operate our business successfully. We may disclose your health information to these business associates so that they can perform the tasks that we hire them to do. Our business associates must guarantee to us that they will respect the confidentiality of your personal and identifiable health information.
Individuals Involved in Your Care or Payment for Your Care. We may disclose information to individuals involved in your care or in the payment for your care, but we will obtain your agreement before doing so. This includes people and organizations that are part of your "circle of care" - such as your spouse or an aide who may be providing services to you. Although we must be able to speak with your other physicians or health care provider, you can let us know if we should not speak with other individuals, such as your spouse or family.
If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest.
To the extent another state or federal law restricts the ability of the practice to use or disclose protected health information as discussed above, the practice's description of the use or disclosure must reflect the more stringent law.
OTHER USES AND DISCLOSURES OF PERSONAL INFORMATION
We are required to obtain written authorization from you for any other uses and disclosures of medical information other than those described above. If you provide us with such permission, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by your written authorization. We will be unable to take back any disclosures already made based upon your original permission.
You have the right to ask for restrictions on the ways in which we use and disclose your medical information beyond those imposed by law. We will consider your request, but we are not required to accept it.
You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail.
Except under certain circumstances, you have the right to inspect and copy medical and billing records about you. A request must be made in writing to inspect and copy your records. If you ask for paper or electronic copies of this information, we will provide this for you usually within 30 days of your request. We may charge you a reasonable, cost-based fee for copying and mailing.
If you believe that information in your record is incorrect or incomplete, you have the right to ask us to correct the existing information or correct the missing information. Under certain circumstances, we may deny your request.
You have a right to ask for a list of instances to whom and why we have used or disclosed your medical information for reasons other than your treatment, payment for services furnished to you, our health care operations, or disclosures you give us authorization to make for six years prior to the date of your request. If you ask for this information from us more than once every twelve months, we may charge you a reasonable, cost-based fee.
You may choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. You have the right to a copy of this Notice in paper form, even if you have agreed to receive the notice electronically. You may ask us for a copy at any time and we will provide you with a paper copy promptly.
You may complain if you feel your rights have been violated by contacting us in writing at Tower Imaging, Inc., 2700 University Square Drive Tampa, FL 33612, (Attn: Privacy Officer), via telephone at 813-253-2721, or e-mail: firstname.lastname@example.org.
You may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting: www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
CHANGES TO THIS NOTICE
We reserve the right to make changes to this notice at any time. We reserve the right to make the revised notice effective for personal health information we have about you as well as any information we receive in the future. In the event there is a material change to the Notice, the revised Notice will be available upon request, in our office, and on our website. In addition, you may request a copy of the revised Notice at any time.
Health and Human Services, at 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C.
20201 (e-mail: email@example.com).
To obtain more information concerning this Notice of Privacy Practices, you may contact our Privacy Officer at
813-253-2721 (e-mail: firstname.lastname@example.org).