THIS NOTICE DESCRIBES HOW MEDICAL, PERSONAL AND FINANCIAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
A. Under federal privacy regulations, you have the right to:
- Receive a copy and explanation of this Notice.
- Understand how we intend to use and share your information with others.
- Look at and/or receive a copy of your health record (subject to some restrictions) and the financial file and personal information we have complied
on you. - Request that your records be changed if you believe the information is
incomplete or incorrect (subject to some restrictions). - Request restrictions on the sharing of the your records/files. *
- Request communications by alternate means or location. *
- File a complaint if you believe your privacy rights have been violated.
* Please note that while we are not required to agree to such requests, we will make an effort to accommodate you when possible
B. Types of Records/Information we Collect/Maintain include, but are not limited to:
- Medical – diagnoses, past medical history, medications, medical treatments, name of physician
- Personal – name, address, phone number, date of birth, social security number, related parties, height and weight
- Financial – insurance information. For scholarship applicants, copy of state or federal tax returns and other pertinent disclosures of financial status to determine eligibility for scholarship aid
C. Our Responsibilities:
- We are required by law to maintain the privacy of, including access to, your medical,personal and financial information and to provide you this Notice of our duties and privacy practices. We are also required to follow the terms of the Notice. You will be promptly notified in writing if there are any major changes to any of the privacy practices of this Notice.
- We will not use or share your information without authorization, except as noted in this Notice (Section D & E).
D. Routine Uses And Disclosures:
We will use and/or share your information to:
- Provide treatment – e.g. coordinate care with our staff and volunteers and other health care providers and/or state and/or federal agencies and other outside organizations (primarily insurers) relative to the nature and extent of services we render and the manner in which we render your services.
- Schedule and/or remind you about schedules visits.
- Collect personal and financial information to be used by us to determine eligibility for direct financial aid from us (scholarships) to pay for the services we render.
- Obtain payment for services provided, e.g. include your diagnosis and other health information on invoices to collect payment for services rendered.
- Record your information in permanent records.
E. Legally Required Disclosures:
We may use and/or disclose protected health, personal and financial information when required by federal, state or local law to:
- Report risks to public health.
- Prevent or lessen serious and imminent threats to health and safety.
- Report abuse, neglect, or domestic violence.
- Respond to inquiries form law enforcement officials, medical review boards, health oversight and financial need agencies.
- Determine financial eligibility for state and or federal programs.
- Respond to requests from governmental agencies responsible for national security.
- Respond to subpoenas for a judicial or administrative proceeding.
- Provide information to coroners, medical examiners or funeral directors.