|
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: (1) maintain
the privacy of medical information provided to us; (2) provide notice of
our legal duties and privacy practices; and (3) abide by the terms of
our Notice of Privacy Practices currently in effect.
WHO WILL
FOLLOW THIS NOTICE:
DRA Imaging PC,
Hudson Valley Radiologists PC, and Imaging Support Services LLC, and all
of their employees and staff, will follow the privacy practices set
forth in this notice. These entities have designed themselves as
affiliated entities, and may share medical information with each other
for the treatment, payment or healthcare operations purposes described
in this notice.
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
medical provider(s).
In addition, we
may gather additional 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 organization that are part of
your “circle of care” – such as the referring physician, other
physicians, 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 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 perform your procedure, in
accordance with our policies and procedures. For example, we will use
your medical history, such as any presence or absence of disease, to
assess your health and perform the requested diagnostic procedure.
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 payer information about your current
medical condition so that it will pay us for your procedure. We may
also need to inform your payer prior to the procedure in order to obtain
prior approval or to determine whether your procedure is covered.
For Healthcare
Operations: We may use or
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 suggest how to improve our services to you.
Public Policy
Uses and Disclosures:
There are several public policy reasons why we may disclose information
about you.
We may disclose
health information about you when we are required by state, federal or
local law.
We may disclose
protected health information 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 protected health information for the purpose of preventing or
controlling disease, injury or disability, or at the direction of a
public health authority. Public health authorities include but are
limited to New York State Health Department, Center for Disease Control,
the Food and Drug Administration (FDA), the Occupational Safety and
Health Administration (OSHA), and the Environmental Protection Agency
(EPA).
We are also
permitted to disclose protected health information to a public health or
other government authority authorized by law to receive reports of
domestic, elder or child abuse or neglect. Additionally we may disclose
protected health information to a person subject to the FDA’s power for
the following activities: to report adverse events, product defects or
problems, or biological product deviations, to track products, to enable
product recalls, repairs or replacements.
We may disclose your
protected health information in response to a judicial subpoena, or a
court or administrative order, and in connection with certain government
investigations and law enforcement activities. We may also disclose
your protected health information in response to a subpoena, discovery
request or other lawful process by someone else involved in the dispute,
but only if efforts have been made to notify you about the request or to
obtain an order protecting the information requested.
We may disclose
health information in connection with health oversight activities of
licensing and other agencies. Health oversight activities include
audit, investigation, inspection, licensure or disciplinary actions, and
civil, criminal, administrative proceeding(s), actions or other
activities necessary for the oversight of 1) the healthcare system, 2)
government 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 to
determine compliance with program standards, or 4) entities subject to
civil right laws for which health information is necessary for
determining compliance.
We may release
personal health information to a coroner or medical examiner to identify
a deceased person or determine the cause of death.
We may release
your personal health information to workers’ compensation or similar
programs.
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.
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.
If you are a member
of the Armed Forces, domestic or foreign, we may release personal health
information about you as required by military command authorities.
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.
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 or foreign heads
of state.
Our Business
Associates: We sometimes
work with outside businesses and individuals who assist us in operating
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.
Individual
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, your other physicians, or an
aide who may be providing services to you. Although we must be able to
speak with your other physicians or health care providers, you can let
us know if we should not speak with other individuals, such as your
spouse or family.
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.
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.
Other Uses
and Disclosures of Personal Information:
We are required to obtain written authorization from you for any 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 anytime. If you revoke your permission, we will no longer
use or disclose 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.
INDIVIDUAL
RIGHTS:
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. Our policy is to
not agree to such requests.
You have the right
to request that you receive communications containing your protected
health information from us in a certain way or at a certain location.
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. If you request copies, we may charge you a
fee for copying and mailing.
If you believe that
information in your records 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 when we have used or disclosed your medical
information for reasons other than treatment, payment for services, our
healthcare operations, or disclosures you gave us authorization to make.
If you ask for this more that once in a 12-month period, we may charge
you a fee.
You have a right to
a copy of this notice. You may ask us for a paper copy or you may
obtain a copy at our web site at
www.draimaging.com.
To exercise any of
your rights, please contact us in writing at:
DRA Imaging, P.C.
Atten: File Room
1 Columbia Street
Poughkeepsie, NY
12601
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 this notice, the revised notice
will posted in the office and updated on our web site.
COMPLAINTS /
COMMENTS:
You may contact
Laurie Wadsworth, at DRA Imaging, P.C. (845) 454-4700 ext. 174.
If you have any
complaints concerning our Privacy Policy, you may contact the Secretary
of the Department of Health & Human Services, at 200 Independence Ave.
S.W., Room 509F, HHH Building, Washington, D.C. 20201 (email:
ocrmail@hhs.gov)
To obtain more
information concerning this Notice of Privacy Practices, you my contact
our Privacy Officer, Mark Newton, at (845) 454-4700 ext. 112
Receipt of
Notice of Privacy Practice
I,
________________________________________________ have
received a copy of the Notice of Privacy Practices from DRA Imaging, PC,
Hudson Valley Radiologists, PC, and Imaging Support Services, LLC,
concerning how the use or disclosure of Protected Health Information
will be handled by the practice.
________________________________________ _______________________
Patient
Signature
Date
Note: Patient:
___________________________________ has refused to sign Receipt of
Notice of Privacy Practices.
Employee Signature:
________________________________ Date: ______________
This document will be kept with the
patient ‘s permanent file.
|
