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G.T.B. MEDICAL SERVICE, INC. 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 THIS NOTICE CAREFULLY.
EFFECTIVE April 14, 2003
Our Commitment to Your Privacy
G.T.B. Medical, Inc. is dedicated to maintaining the
privacy of your identifiable health information. In conducting our business,
we will create records regarding you and the treatment and services we provide
you. We are required by law to maintain the confidentiality of health
information that identifies you. We also are required by law to provide you
with this notice of our legal duties and privacy practices concerning your
identifiable health information. By law, we must follow the terms of the
Notice of Privacy Practices that we have in effect at the time.
To summarize, this notice provides you with the following
information:
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How we may use and disclose your identifiable health information;
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Your privacy rights in your identifiable health information;
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Our obligations concerning the use and disclosure of your identifiable
health information.
The terms of this notice apply to all records containing
your identifiable health information that are created or retained by our
organization. We reserve the right to revise or amend our Notice of
Privacy Practice. Any revision or amendment to this notice will be
effective for all of your records our organization has created or maintained
in the past, and for any of your records we may create in the future.
If you have any questions about this notice, please
contact G.T.B. Medical, Inc.
We may use and disclose your information in the
following ways:
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Treatment. We may use your identifiable information to
provide supplies and services to you. For example, we ask you to provide
us with such information as body weight, height , etc. Many of the
people who work for us may use or disclose your identifiable health
information in order to provide supplies and services to you or to
assist others in your treatment. Additionally, we may disclose your
identifiable health information to others who may assist in your care,
such as your physician, therapists, spouse, children or parents.
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Payment. We may use and disclose your identifiable
health information in order to bill and collect payment for the services
and supplies you may 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 supplies and/or services. We may also use and disclose your
identifiable health information to obtain payment from third parties
that may be responsible for such costs, such as family members. Also, we
may use your identifiable health information to bill you directly for
services and supplies.
-
Health Care Operations. We may use and disclose your
identifiable health information to operate our business. As examples of
the ways in which we may use and disclose your health information for
our operations, we may use your health information to evaluate the
quality of care you receive from us, or to conduct cost-management and
business planning activities for our business.
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Appointment Reminders. We may use and disclose your
identifiable health information to contact you and remind you of
visits/deliveries.
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Health-Related Benefits and Services. We may use your
identifiable health information to inform you of health-related benefits
or services that may be of interest to you.
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Release of Information to Family / Friends. We may
release your identifiable health information to a friend or family
member that is helping you pay for your health care, or who assists in
taking care of you.
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Disclosures Required By Law. We will use and disclose
your identifiable health information when we are required to do so by
federal, state or local laws.
Use and Disclosure of Your Identifiable Health
Information in Certain Special Circumstances
The following categories describe unique scenarios in which we
may use or disclose your identifiable health information:
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Public Health Risk. We may disclose your identifiable
health information to public health authorities that are authorized by
law to collect information for the purpose of:
- 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 information.
- Health Oversight Activities. We may disclose your
health information 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.
- Lawsuits and Similar Proceedings. We may use and
disclose your identifiable health information in response to a court or
administrative order, if you are involved in a lawsuit or similar
proceeding. We also may disclose your identifiable health in response to a
discovery request, subpoena, or other lawful process by another party
involved in a dispute, but only if we have made an effort to inform you of
the request or to obtain an order protecting the information the party has
requested.
- Law Enforcement. We may release identifiable health
information 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 might have resulted from criminal
conduct;
- Regarding criminal conduct in 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;
- In an emergency, to report a crime (including the location or
victim(s) of the crime, or the description, identity, or location of
the perpertrator).
- Serious Threats to Health or Safety. We may use and
disclose your identifiable health information 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 disclosures to a person or organization able to help
prevent the threat.
- Military. We may disclose your identifiable health
information if you are a member of U.S. or foreign military forces
(including veterans) and if required by the appropriate military command
facilities.
- National Security. We may disclose your identifiable
health information to federal officials for intelligence and national
security activities authorized by law. We also may disclose your
identifiable health information to federal officials in order to protect
the President, other officials or foreign heads of state, or to conduct
investigations.
- Inmates. We may disclose your identifiable health
information to correctional institutions or law enforcement officials if
you are an inmate or under the custody of a law enforcement official.
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.
- Workers' Compensation. We may release your identifiable
health information for workers' compensation and similar programs.
- Coroners, Medical Examiners and Funeral Directors. We
may disclose health information to a coroner or medical examiner. We may
also disclose medical information to funeral directors consistent with
applicable law to carry out their duties.
- Organ Procurement Organizations. Consistent with
applicable law, we may disclose health information to organ procurement
organizations or entities engaged in the procurement, banking, or the
transportation of organs for the purpose of tissue donation and
transplant.
- Research. We may disclose information to researchers
when their research has been approved by an Institutional Review Board or
Privacy Board that has reviewed the research proposal and established
protocols to ensure the privacy of your healthcare information.
Your Rights Regarding Your Identifiable Health
Information
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Confidential Communications. You have the right to
request that we 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 us, specifying the requested method of contact or location
where you wish to be contacted. We will accommodate reasonable requests.
You do not need to give a reason for your request.
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Requesting Restrictions. You have the right to request
a restriction in our use or disclosure of your identifiable health
information for treatment, payment or health care operations.
Additionally, you have the right to request we limit our disclosure of
your identifiable health care information to 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. In order to request a restriction in our use or disclosure of
your identifiable health information, you must make your request in
writing to us. Your request must describe in clear and concise fashion:
(a) the information you wish restricted; (b) whether you are requesting
to limit our use, disclosure or both; and (c) to whom you want the
limits to apply.
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Inspection and Copies. You have the right to inspect
and obtain a copy of the identifiable health information that may be
used to make decisions about you, including patient medical records and
billing records, but not including psychotherapy notes. You must submit
your request in writing to us in order to inspect and/or obtain a copy
of your identifiable health information. We may charge a fee for the
costs of copying, mailing, labor and supplies associated with your
request. We may deny your request to inspect and/or copy in certain
limited circumstances; however, you may request a review of our denial.
Reviews will be conducted by another licensed health care professional
chosen by us.
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Amendment. You may ask us to amend your health
information if you believe it to be incorrect or incomplete, and you may
request an amendment for as long as the information is kept by or for
us. To request an amendment, your request must be made in and submitted
to us in writing. You must provide us with a reason that supports your
request for amendment. We will deny your request if you fail to submit
your request (and the reason supporting your request) in writing. Also,
we may deny your request if you ask us to amend information that is: (a)
accurate and correct; (b) not part of the identifiable health
information kept by or for us; (c) not part of the identifiable health
information which you would be permitted to inspect and copy; (d) not
created by us, unless the individual or entity that created the
information is not available to amend the information.
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Accounting of Disclosurers. All of our patients have
the right to request an "accounting of disclosures." An
"accounting of disclosures" is a list of certain disclosures
we have made of your identifiable health information. In order to obtain
an accounting of disclosures, you must submit your request in writing to
our office. All requests for an "accounting of disclosures"
must state a time period which may not be longer than six years and may
not include dates before April 14, 2003. The first list you request
within a 12 month period is free of charge, but we may charge you for
additional lists within the same 12 month period. We will notify you of
the cost involved with additional requests, and you may withdraw your
request before you incur any costs.
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Right to a Paper Copy of This Notice. You are entitled
to receive a paper copy of our Notice of Privacy Practices. You may ask
us to give you a copy of this notice at any time. To obtain a paper copy
of this notice, contact our office.
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Right to File a Complaint. If you believe your privacy
rights have been violated, you may file a complaint with us or with the
Office of Civil Rights. All complaints must be in writing. You
will not be penalized for filing a complaint.
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Right to Provide an Authorization for Other Uses and
Disclosures. We will obtain your written authorization for uses
and disclosures that are not identified by this notice or permitted by
applicable law. Any authorization you provide to us regarding the use
and disclosure of your identifiable health information may be revoked at
any time in writing. After you revoke your authorization, we will
no longer use or disclose your identifiable health information for the
reasons described in the authorization. Please note, we are required to
retain records of your care.
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