Privacy Notice

This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. As required by "HIPAA," we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

Protected Information: While receiving care from our facility, information regarding your medical history, treatment, and payment for your health care may be originated and/or received by us. Information which can be used to identify you and which relates to your medical care or your payment for your medical care is protected by state and federal law ("Protected Information").

Your Rights: Federal law grants you certain rights with respect to your Protected Information. Specifically you have the right to:

• Receive notice of our policies and procedures used to protect your Protected Information.
• Request that certain uses and disclosures of your Protected Information to be restricted; provided, however, we have the right to refuse your request.
• Access to your Protected Information; provided, however, the request must be in writing and may be denied in certain limited situations.
• Request that your Protected Information be amended.
• Obtain an accounting of certain disclosures by us of your Protected Information for the past six years, starting April 14, 2003.
  
• Revoke in writing any prior authorizations for use or disclosure of Protected Information, except to the extent that action has already been taken.
• Request communications of your Protected Information are done by reasonable alternative means or at alternative locations.

Our Responsibilities:

• Provide you with notice of our legal duties and our facility's policies regarding the use and disclosure of your protected information.
• Maintain the confidentiality of your Protected Information in accordance with state and federal law.
• Allow you to inspect and request a copy(s) of your Protected Information during our regular business hours pursuant to any legal restrictions. A copying charge of 50 cents per sheet may be charged.
• Review your requested restrictions regarding the use and
  disclosure of your Protected Information and inform you if these restrictions will be used.
• Act on your request to amend Protected Information within sixty (60) days and notify you of any delay which would require us to extend the deadline by the permitted thirty (30) day extension.
• Accommodate reasonable requests to communicate Protected Information by alternative means or methods.
• Abide by these terms of this notice.
  

How Your Protected Information May be Used and Disclosed: Generally, your Protected Information may be used and disclosed for treatment, payment or operations as required by law. This includes a variety of areas:

• Treatment Purposes: We may use or disclose your Protected Information for treatment purposes, including continuing care and case or care management. During your care at our facility, it may be necessary for various personnel, including, but not limited to, physicians, physician's assistants, x-ray technicians, nurses, lab technicians, or medical students, involved in your care to have access to your Protected Information in order to provide you with quality care. For example, your physician may need to know which medications you are currently taking before prescribing additional medications.
  Situations may also arise when it is necessary to disclose your Protected Information to individuals outside our facility who may also be involved in your current or future care. For example, if you are a resident in a nursing facility, it may be necessary for your physician to disclose medications pre scribed by him/her so that they can be appropriately administered by the nursing facility and side effects may be monitored. The nursing facility may disclose information to the hospital if admission is required, or to a specialist. Your physician may call a pharmacist and order a prescription.
• Payment Purposes: Your Protected Information may be used or disclosed for payment purposes. It is necessary for us to use or disclose Protected Information so that treatment and services provided by us may be billed and collected from you, your insurance company, or other third party payer. Bills requesting payment will usually include information, which identifies you, your diagnosis, and any procedures or supplies used. It may also be necessary to release Protected Information to obtain prior approval for treatment from your health insurance.
• Health Care Operations: Your Protected Information may be used for facility operations, which are necessary to ensure our facility provides the highest quality of care. For example, your Protected Information may be used for learning or quality assurance purposes. We may also remove information, which could identify you from your record so as to prevent others from learning who the specific patients are.
• Emergency Use: If an emergency situation exists, and providing you with this notice is not practicable, we may use or disclose Protected Information to the extent necessary during the emergency.
• Notification: Unless you have informed us otherwise, your Protected Information may be used or disclosed by us to notify or assist in notifying you, a family member, or other person responsible for your care. This may include appointment reminders such as postcards. In most cases, Protected Information disclosed for notification purposes will be limited to your name, location and general condition.
• Communication with Family Members and Care-givers: We may release Protected Information to a family member, relative, or close personal friend who is involved in your care to the extent necessary for them to participate in your care.
• Research Purposes: In some instances, your Protected Information may be used or disclosed for research purposes. All research projects, which use Protected Information, are subject to a special approval process that will, among other things, evaluate the precautions used to protect the patient medical information. In most cases, but not all, information which identifies you as the patient will be removed.

Special Circumstances: The law specifically requires us to use or disclose Protected Information in the following special circumstances.

• Public Health Activities: We are required to use or disclose your Protected Information for public health activities and purposes. Examples of public health activities which would warrant the use of your Protected Information include:
  • Reporting or controlling disease, injury or disability.
  • Reporting births or deaths.
  • Reporting the abuse or neglect of a child or dependent adult.
  • Reporting reactions to medications or problems with products.
  • Notifying individuals exposed to a disease who may be at risk for contracting or spreading the disease.
  • Periodic State of Iowa immunization audits.
• Health Oversight Activities: Your Protected Information may be used or disclosed to a health oversight agency for activities authorized by law. Examples of health oversight activities include audits, investigations, inspections or judicial/administrative proceedings, which you are not the subject of. In most cases, the oversight activity will be for the purpose of overseeing the care rendered by our facility or our facility's compliance with certain laws and regulations.
• Judicial and Administrative Proceedings: If you are involved in a lawsuit or other administrative proceeding, we may release your Protected Information in response to a court or administrative order requesting the release. In  some instances, we may also release Protected Information pursuant to a subpoena or discovery request but only if efforts have been made by the requestor to provide you with notice of the request and you have failed to object or the objection was resolved in favor of disclosure, or in the alternative, the requestor has obtained a protective order protecting the requested information.
• Victims of Abuse or Neglect: Other than child and dependent adult abuse, which is covered under public health activities, we may use or disclose your Protected Information to a protective services or social services agency or other similar government authority, if we reasonably believe you have been the victim of abuse, neglect or domestic violence as long as you agree to such disclosure and we feel it is necessary to prevent serious harm to you or other individuals. If you are incapacitated and unable to agree to such a disclosure, we may release your Protected Information for this purpose but only if failure to release it would materially and adversely affect a law enforcement activity and the information will not be used, in any way, against you.
• Law Enforcement: We may also release your Protected Information to a law enforcement official for the following purposes:
  • Pursuant to a court order, warrant, subpoena/summons, or administrative request.
  • Identifying or locating a suspect, fugitive, material witness or missing person.
  • Regarding a crime victim, but only if the victim consents or the victim is unable to consent due to incapacity and the information is needed to determine if a crime has occurred, non-disclosure would significantly hinder the investigation, and disclosure is in the victim's best interest.
  • Regarding a decedent, to alert law enforcement that the individual's death was caused by suspected criminal conduct.
  • By emergency care personnel if the information is necessary to alert law enforcement of a crime, the location of a crime, or characteristics of the perpetrator or if the emergency involves circumstances legally requiring disclosure to law officials (i.e. gunshot wounds).
• Coroner, Medical Examiners, Funeral Homes: Protected Information regarding a decedent may be released to a coroner or medical examiner for the purpose of identifying a deceased person, determining cause of death or other duties as authorized by law. Protected Information regarding a decedent may also be disclosed to funeral directors if necessary to carry out their duties.

Specialized Government Functions: Your Protected Information may be used or disclosed for a variety of government functions subject to some limitations. These government functions include:

• Military and veteran activities
• National security and intelligence activities
• Protective service of the President and others
• Medical suitability, determinations for Department of State Officials
• Correctional institutions and law enforcement custodial situations
• Provision of public benefits.

Organ Donation: Your Protected Information may be used or disclosed by us to entities engaged in the procurement, banking or transplantation of organs, eyes or tissues for the purpose of facilitating such donation and transplantation.

Workers' Compensation: We will disclose your Protected Information and to the extent necessary to comply with laws relating to workers' compensation or other programs providing benefits for work-related injuries or illness without regard to fault.

Inmates: If you are an inmate of a State or Federal institution or under the custody of law enforcement, we may release medical information about you to the institution, law enforcement official or court, if this release is necessary.

• For the institution to provide you with healthcare.
• To protect your health and safety, and/or the health and safety of others.
• For the safety and security of the correctional institution or agency.
  

Important Contact Information:
This notice has been provided to you as a summary of how we will use your Protected Information and your rights with respect to your Protected Information. If you have any questions or for more information regarding your Protected Information, please contact the Family Medical Center Business Office.

If you believe that your privacy rights have been violated, you may file a complaint with our office by contacting the Family Medical Center Business Office.

For more information about HIPAA or to file a complaint you may notify:
The U.S. Department of Health and Human Service Office of Civil Rights
200 Independence Avenue, S.W.
Washington D. C. 20201
(202) 619-0257 or Toll Free: 1-877-696-6775

Effective Date and Revisions:
This notice becomes effective on July 7, 2007. Please note: We reserve the right to revise this notice at any time. Should we revise this notice; the revised notice will be available at the Family Medical Center Business Office. In addition, a current copy of our notice of privacy practices may be obtained from our Business Office.
Form PP01

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