Effective Date: September 23, 2013
PRAIRIE FIELDS FAMILY MEDICINE, P.C. NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS
TO YOUR MEDICAL INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
OUR COMMITMENT TO YOUR PRIVACY
Prairie Fields Family Medicine, P.C. 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 to 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 Privacy Practices (“Notice”) setting forth our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the Notice that we have in effect at the time.
This Notice provides you with the following important information:
- How Prairie Fields Family Medicine, P.C. may use and disclose your identifiable health information;
- Your privacy rights in your identifiable health information; and
- Prairie Fields Family Medicine, P.C.’s 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 Prairie Fields Family Medicine, P.C. We reserve the right to revise or amend our Notice of Privacy Practices. Any revision or amendment to this Notice will be effective for all of your records Prairie Fields Family Medicine, P.C. has created or maintained in the past, and for any of your records we may create or maintain in the future. We will post a copy of our current Notice in each of our facilities in a prominent location, and you may request a copy of our most current Notice during any visit. The effective date of our Notice will be posted in the upper left-hand corner of the Notice.
WHO WILL FOLLOW THIS NOTICE
The privacy practices of Prairie Fields Family Medicine, P.C., apply to:
any health care professional authorized to enter information into your medical records, including members of our medical staff;
all departments, units and offices operated by Prairie Fields Family Medicine, P.C.; and
all employees, staff and other personnel of Prairie Fields Family Medicine, P.C.
All of these individuals and locations will follow the terms of this Notice. In addition, these individuals and locations may share health information with each other for treatment, payment or health care operations purposes as described in this Notice.
HOW WE MAY USE AND DISCLOSE YOUR IDENTIFIABLE HEALTH INFORMATION
The following categories describe different ways in which we may use and disclose your identifiable health information. For each category of uses or disclosures we will explain what we mean and provide examples. Not every use or disclosure in a category will be listed; however, all of the ways we are permitted to use and disclose information will fall within one of the categories. Please realize, in some instances Nebraska has special laws concerning the use and disclosure of certain types of health information, such as mental health, substance abuse and HIV/AIDS information.
Treatment. We may use health information about you to provide you with health treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at Prairie Fields Family Medicine, P.C. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Prairie Fields Family Medicine, P.C. may share health information about you with others in order to coordinate the different things you need, such as prescriptions, lab work, x-rays and follow-up care. To the extent permitted by law, we also may disclose health information about you to people outside Prairie Fields Family Medicine, P.C. who may be involved in your health care (such as family members, home health agencies and others that provide services that are part of your care).
Payment. We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment may be collected from you, an insurance company or a third party. We also may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We also may disclose your health information to other health care providers and health plans for the payment activities of those providers and plans. For example, we may provide your information to a physician who is not on our medical staff so that the physician may bill you or your insurer for the services you received from that physician.
Health Care Operations. Prairie Fields Family Medicine, P.C. may use and disclose health information about you for administrative and operational purposes. These uses and disclosures are necessary for our operations, and to make sure that all of our patients receive quality care. For example, we may use your health information to review our treatment and services and to evaluate our performance in caring for you. We may combine health information about some or all of our patients to decide what additional services we should offer, what services may not be needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and our personnel for review and learning purposes. We may also combine the health information we have with health information from other health care providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific patients are. We also may disclose your health information to certain other individuals and organizations, including physicians, hospitals and health plans, to assist with certain health care operations activities of these individuals and organizations. Except for those individuals and organizations described in the section of this Notice entitled “Who Will Follow This Notice,” these individuals and organizations either have or had in the past a relationship with you.
The information we disclose about you will relate to this relationship. For example, we may disclose your health information to a hospital if that hospital has treated you in the past, the information we disclose relates to that relationship, and the hospital intends to use your information for its quality assurance and improvement activities. Similarly, we may share your health information with your health plan for quality assurance and improvement purposes. These are but some of the various permissible uses and disclosures Prairie Fields Family Medicine, P.C. may engage in as part of routine health care operations.
Business Associates. We may provide health information to entities that provide services for Prairie Fields Family Medicine, P.C. We require these business associates to protect the health information we provide to them.
Appointment Reminders. We may use and disclose your health information to contact you as a reminder that you have an appointment for treatment or medical care.
Treatment Options. We may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services. We may use and disclose your health information to tell you about health-related benefits or services that may be of interest to you.
Release of Information to Family/Friends. We may release your 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. Further, in the event of your death, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your health information that directly relates to that person’s involvement in your health care or who has responsibility for payment of your health care, unless such disclosure is inconsistent with your prior expressed preference that is known to us.
In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
As Required By Law. We will use and disclose your health information when we are required to do so by federal, state or local law.
USE AND DISCLOSURE OF YOUR IDENTIFIABLE HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe circumstances in which we may use or disclose your identifiable health information:
Public Health Risks. We may disclose health information about you for state and federal public health activities. These activities generally include the following:
- to report, prevent or control disease, injury or disability;
- to report births and deaths;
- to report child abuse or neglect;
- to report reactions to medications or problems with products;
- to notify people of recalls of products they may be using;
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
- to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence.
We will only make these disclosures if you agree or when we are otherwise required or authorized by law to do so.
Health Oversight Activities. We may disclose your health information to a state or federal health oversight agency for activities authorized by law. These oversight activities 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 Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We also may disclose your health information in response to a subpoena, discovery request, or other lawful process by another party involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may release health information if asked to do so by a local, state or federal law enforcement official:
- in response to a court order, subpoena, warrant, summons or similar process;
- to identify or locate a suspect, fugitive, material witness, or missing person;
- about the victim of a crime in certain limited circumstances, if we are unable to obtain the person’s agreement;
- about a death we believe may be the result of criminal conduct;
- about criminal conduct at any Prairie Fields Family Medicine, P.C. facility; and
- in emergency circumstances to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).
Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about our patients to funeral directors as necessary to carry out their duties.
Organ and Tissue Donation. If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Research. We may use and disclose health information about you for research purposes in certain limited circumstances. For example, a research project may involve comparing the health of all patients who received one medication to those who received another, for the same condition. All research projects are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patients’ need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process, however, we may disclose health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific health needs, so long as the health information they review does not leave our premises. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care.
Serious Threats to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat and/or to any specifically identified victims of the threat.
Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
National Security and Intelligence Activities. We may disclose your health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official. Disclosure for these purposes would be necessary: (1) for the institution to provide health care services to you; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Employers. We may disclose to your employer health information obtained in providing medical services to you at the request of your employer for purposes of conducting an evaluation relating to medical surveillance of the workplace or determining whether you have a work-related illness or injury when such medical services are needed by the employer to comply with certain legal requirements.
Schools. We may disclose proof of immunizations to a school you attend or will attend if the school is required by state or other law to have such proof prior to admitting you and if we obtain your consent or, if you are a minor, the consent of a parent, guardian or person acting in loco parentis.
In the event your unsecured health information has been accessed, acquired, used or disclosed in a manner not permitted by law which compromises the security or privacy thereof, we are required by law to notify you of such breach within 60 days after we have discovered the breach.
YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION
You have the following rights regarding the identifiable health information we maintain about you:
Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we contact you at work or by U.S. Mail. To request that we contact you in a certain way or at a certain location, you must make your request in writing to: Administrator, Prairie Fields Family Medicine, P.C., 350 W. 23rd Street, Suite A, Fremont, NE 68025. We will not ask you the reason for your request, and we will accommodate reasonable requests.
Your written request must specify how or where you wish to be contacted. You must provide us with a mailing address where you can receive correspondence and other communications from us related to payment for the services you have received from us. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your health information for treatment, payment or healthcare operations purposes. You also have the right to request that we limit our disclosure of your health information to individuals involved in your care or the payment for your care, such as family members and friends. Prairie Fields Family Medicine, P.C. is not required to agree to your request unless the restriction involves the disclosure to a health plan for purposes of carrying out payment or health care operations and such health information pertains solely to a health care item or service for which you paid out-of-pocket in full. NOTE: If we do agree, we will strive to comply with your request unless your information is needed to provide emergency treatment to you. However, Prairie Fields Family Medicine, P.C. cannot ensure complete success.
We may terminate our agreement to restrict uses and disclosures of your health information by providing you with written notice of such; provided, however, that our termination shall only be effective with respect to health information created or received after we have given you notice of termination of the restriction. Further, we may not terminate a restriction that we are required to agree to with respect to disclosures to health plans, which is described above.
To formally request a restriction, you must make your request in writing to: Administrator, Prairie Fields Family Medicine, P.C., 350 W. 23rd Street, Suite A, Fremont, NE 68025. In your request, you must describe in a clear and concise fashion: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Prairie Fields Family Medicine, P.C. does not have the authority to bind anyone else to any restrictions to which Prairie Fields Family Medicine, P.C. may agree.
Inspection and Copies. You have the right to inspect and copy health information that may be used to make decisions about your care, including your medical records and billing records, but not including: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and certain laboratory information restricted by federal law. Prairie Fields Family Medicine, P.C. will respond to your written request within thirty (30) days, unless state law requires us to respond earlier.
If we maintain your health information electronically, we will provide you with a copy of your medical record in the electronic form and format that you request, if we can readily produce such format. If we cannot readily produce the format you requested, we will produce your electronic health information in at least one readable electronic format as agreed to between you and us.
If your request directs us to transmit the copy of your health information directly to another person, we will provide the copy of your health information to the person you designated, if your request was made in writing, signed by you and clearly identifies the designated person and where to send the copy of your health information.
To formally inspect or obtain a copy of your health information that is maintained by or on behalf of Prairie Fields Family Medicine, P.C. and that may be used to make decisions about you, you must submit your request in writing to Administrator, Prairie Fields Family Medicine, P.C.,
350 W. 23rd Street, Suite A, Fremont, NE 68025. Prairie Fields Family Medicine, P.C. may charge a reasonable fee for the costs of copying, mailing, labor and supplies associated with your request.
We may deny your request to inspect and copy your health information under certain limited circumstances. For example, you may not be provided with your health information if it is determined that providing such information could cause harm to you or another person. In most cases, if you are denied access to health information you may request that the denial be reviewed. Prairie Fields Family Medicine, P.C.’s physicians, in accordance with applicable law, will review your request and the denial. The person conducting the review will not be the person who denied your request. The Prairie Fields Family Medicine, P.C. department that originally denied you access will comply with the outcome of the review.
Amendment. If you feel that health information Prairie Fields Family Medicine, P.C. has about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Prairie Fields Family Medicine, P.C.
To formally request an amendment of health information that is maintained by or on behalf of Prairie Fields Family Medicine, P.C. about you, your request must be made in writing and submitted to: Administrator, Prairie Fields Family Medicine, P.C., 350 W. 23rd Street, Suite A, Fremont, NE 68025. In addition, you must provide a reason that supports your request.
Prairie Fields Family Medicine, P.C. may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, Prairie Fields Family Medicine, P.C. may deny your request if you ask to amend information that:
- Is accurate and complete;
- Was not created by Prairie Fields Family Medicine, P.C., unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the health information kept by or for Prairie Fields Family Medicine, P.C.; or
- Is not part of the information which you would be permitted to inspect and copy.
Accounting of Disclosures. You have the right to receive an accounting of certain disclosures we have made, if any, of your health information. This right applies to disclosures made for purposes other than (i) treatment, payment or health care operations, unless such disclosures are made through an electronic health record maintained by us; (ii) disclosures made to the patient; (iii) disclosures to a facility directory; (iv) disclosures to family members or friends involved in the patient’s care or for notification purposes; or (v) disclosures pursuant to an authorization. To request an accounting of disclosures made by Prairie Fields Family Medicine, P.C., you must submit your request in writing to: Health Record Custodian, Prairie Fields Family Medicine, P.C. 350 W. 23rd Street, Suite A, Fremont, NE 68025. Your request must state a time period that may not be longer than six years (three years for disclosures made through an electronic health record maintained by us) and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, you may be charged for the costs of providing the list. You will be notified of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. To obtain a paper copy of this Notice, contact the Administrator, Prairie Fields Family Medicine, P.C. 350 W. 23rd Street, Suite A, Fremont, NE 68025. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
RIGHT TO FILE A COMPLAINT
If you believe your privacy rights have been violated, you may file a complaint with the Administrator, Prairie Fields Family Medicine, P.C. 350 W. 23rd Street, Suite A, Fremont, NE 68025.
You may also submit a complaint to the Secretary of the Department of Health & Human Services at 200 Independence Ave SW, Washington, DC, 20210 or by calling toll free 1-877-696-6775.
All complaints must be submitted in writing. The Office of Civil Rights of HHS provides information on its website about how to file a complaint: www.hhs.gov/ocr/hipaa/. You will not be penalized for filing a complaint.
RIGHT TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES
We may only use and disclose your psychotherapy notes for purposes other than certain treatment, payment or health care operations with your written authorization. We may only use and disclose your health information for marketing purposes with your written authorization, except if the communication is in the form of face-to-face communication made by us to you or is a promotional gift of nominal value from us to you. We may only sell your health information with your written authorization. Further, any other uses and disclosures of your health information for purposes other than those described above in this Notice will be made only with your written authorization. Any authorization you provide to us regarding the use and disclosure of your 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 medical care.
If you have any questions about this Notice, please contact Prairie Fields Family Medicine, P.C. at (402) 721-7077.