††††††††††††††† ††††††††††††††† ††††††† ††††††† Original Effective Date:† April 14, 2003
MICHIANA ANESTHESIA CARE, P.C.
605 PORTAGE AVENUE
SOUTH BEND, IN† 46616
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 REVIEW IT CAREFULLY.
We are required by law to protect the privacy of health information that may reveal your identity, and to provide you with a copy of this notice which describes the health information privacy practices of our Anesthesia and Pain Practice and any affiliated health care providers that jointly perform payment activities and business operations with our practice. We are required to abide by the terms of the notice currently in effect.† A copy of our current notice will always be posted in our reception area. You will also be able to obtain your own copies by accessing our website at www.macsb.com, calling our office at (574) 232-8119, or asking for one at the time of your next visit.† Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
If you have any questions about this notice or would like further information, please contact:
††††††††††††††††††††††† ††††††††††† ††††††††††† Privacy Officer
††††††††††††††††††††††† ††††††††††† ††††††††††† Michiana Anesthesia Care, P.C.
††††††††††††††††††††††† ††††††††††† ††††††††††† 605 Portage Avenue
††††††††††††††††††††††† ††††††††††† ††††††††††† South Bend, Indiana† 46616
††††††††††††††††††††††† ††††††††††† ††††††††††† (574) 232-8119
IMPORTANT SUMMARY INFORMATION
Requirement for Acknowledgment of Notice of Privacy Practices. We will ask you to sign a form that will serve as an acknowledgment that you have received this Notice of Privacy Practices.
Requirement For Written Authorization. We will generally obtain your written authorization before using your health information or sharing it with others outside our group practice. You may also initiate the transfer of your records to another person by completing an authorization form. If you provide us with written authorization, you may revoke that authorization at any time, except to the extent that we have already relied upon it. To revoke an authorization, please contact the Privacy Officer.
Exceptions To Requirement. There are some situations when we do not need your written authorization before using your health information or sharing it with others. They are:
How To Access Your Health Information. You generally have the right to inspect and copy your health information. Details about this right are provided below.
How To Correct Your Health Information. You have the right to request that we amend your health information if you believe it is inaccurate or incomplete. A description of this right is included below.
How To Keep Track Of The Ways Your Health Information Has Been Shared With Others. You have the right to receive a list from us, called an "accounting list," which provides information about when and how we have disclosed your health information to outside persons or organizations. The list will identify non-routine disclosures of your information, but routine disclosures will not be included. The list will not include disclosures you have authorized. For more information about your right to see this list, see below.
How To Request Additional Privacy Protections. You have the right to request further restrictions on the way we use your health information or share it with others. We are not required to agree to the restriction you request, but if we do, we will be bound by our agreement.
How To Request More Confidential Communications. You have the right to request that we contact you in a way that is more confidential for you, such as at home instead of at work. We will try to accommodate all reasonable requests.
How Someone May Act On Your Behalf. You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control the privacy of health information about minors unless the minors are permitted by law to act on their own behalf.
How To Learn About Special Protections For HIV, Substance Abuse, and Mental Health Information. Special privacy protections apply to HIV-related information, substance abuse information, and mental health information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you will be provided with separate notices explaining how the information will be protected. To request copies of these other notices now, please contact the Privacy Officer at (574) 232-8119.
How To Obtain A Copy Of This Notice. You have the right to a paper copy of this notice. You may request a paper copy at any time, even if you have previously agreed to receive this notice electronically. To do so, please call the Privacy Officer or Administrator at (574) 232-8119.† You may also obtain a copy of this notice from our website at www.macsb.com, or by requesting a copy at your next visit.
How To Obtain A Copy Of Revised Notices. We may change our privacy practices from time to time. If we do, we will revise this notice so you will have an accurate summary of our practices. The revised notice will apply to all of your health information, and we will be required by law to abide by its terms. We will post any revised notice in our reception area. You will also be able to obtain your own copy of the revised notice by accessing our website at www.macsb.com, calling our office at (574) 232-8119, or asking for one at the time of your next visit. The effective date of the notice will always be located in the top right corner of the first page.
How To File A Complaint. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact the following:
††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††† Privacy Officer
††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††† Michiana Anesthesia Care, P.C.
††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††† 605 Portage Avenue
††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††† South Bend, IN† 46616
††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††† (574) 232-8119
†No one will retaliate or take action against you for filing a complaint.
WHAT HEALTH INFORMATION IS PROTECTED
We are committed to protecting the privacy of information we gather about you while providing health-related services. Some examples of protected health information are:
WHO THIS NOTICE APPLIES TO
This notice describes Michiana Anesthesiology Care, P.C.'s (MAC) practices and those of:
∑ MACís physicians and office staff personnel who are authorized to consult your medical record.
∑ Any consultants hired by MAC to perform compliance reviews of your medical record.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION
1. Treatment, Payment, And Normal Business Operations
The physicians and other clinicians and staff members within our Practice may use your health information or share it with others in order to treat your condition, obtain payment for that treatment, and run the practice's normal business operations. Your health information may also be shared with affiliated hospitals and health care providers so that they may jointly perform certain payment activities and business operations along with our practice. Below are further examples of how your information may be used for treatment, payment, and health care operations.
Treatment. We may share your health information with doctors or nurses within our practice who are involved in taking care of you, and they may in turn use that information to diagnose or treat you. A doctor within our practice may share your health information with another doctor within our practice, or with a doctor at another health care institution (such as a hospital), to determine how to diagnose or treat you. A doctor in our practice may also share your health information with another doctor to whom you have been referred for further health care.
Payment. We may use your health information or share it with others so that we obtain payment for your health care services. For example, we may share information about you with your health insurance company in order to obtain reimbursement after we have treated you. We may also share information about you with your health insurance company to determine whether it will cover your treatment or to obtain necessary pre-approval before providing you with treatment.
Business Operations. We may use your health information or share it with others in order to conduct our normal business operations. For example, we may use your health information to evaluate the performance of our physicians or staff in caring for you, or to educate our physicians or staff on how to improve the care they provide for you. Additionally, we may share your health information to another health care provider or payor for certain business operations of that entity, if that entity also has a relationship with you.† We may also share your health information with another company that performs business services for us, such as billing companies. If so, we will have a written contract to ensure that this company also protects the privacy of your health information.
Appointment Reminders, Treatment Alternatives, Benefits And Services. We may use your health information when we contact you with a reminder that you have an appointment for treatment or services at our facility. We may also use your health information in order to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you.
2. Friends And Family
We may use your health information in our patient directory, or share it with friends and family involved in your care, without your written authorization. We will always give you an opportunity to object unless there is insufficient time because of a medical emergency (in which case we will discuss your preferences with you as soon as the emergency is over). We will follow your wishes unless we are required by law to do otherwise.
Friends And Family Involved In Your Care. If you do not object, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for that care. We may also notify a family member, personal representative, or another person responsible for your care about your general condition or about the unfortunate event of your death. In some cases, we may need to share your information with a disaster relief organization that will help us notify these persons.
3. Emergencies Or Public Need.
We may use your health information, and share it with others, in order to treat you in an emergency or to meet important public needs. We will not be required to obtain your written authorization, consent or any other type of permission before using or disclosing your information for these reasons.
Emergencies. We may use or disclose your health information if you need emergency treatment or if we are required by law to treat you but are unable to obtain your consent. If this happens, we will try to obtain your consent as soon as we reasonably can after we treat you.
Communication Barriers. We may use and disclose your health information if we are unable to obtain your consent because of substantial communication barriers, and we believe you would want us to treat you if we could communicate with you.
As Required By Law. We may use or disclose your health information if we are required by law to do so. We also will notify you of these uses and disclosures if notice is required by law.
Public Health Activities. We may disclose your health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities. For example, we may share your health information with government officials that are responsible for controlling disease, injury, or disability. We may also disclose your health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if a law permits us to do so. ††
Victims Of Abuse, Neglect, Or Domestic Violence. We may release your health information to a public health authority that is authorized to receive reports of abuse, neglect, or domestic violence. We will make every effort to obtain your permission before releasing this information, but in some cases we may be required or authorized to act without your permission.† If we believe that a person is a victim of child or adult abuse or neglect, we are required by law to report certain information to public authorities.
Health Oversight Activities. We may release your health information to government agencies authorized to conduct audits, investigations, and inspections of our facility. These government agencies monitor the operation of the health care system, government benefit programs, such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws.
Product Monitoring, Repair And Recall. We may disclose your health information to a person or company that is required by the Food and Drug Administration to: (1) report or track product defects or problems; (2) repair, replace, or recall defective or dangerous products; or (3) monitor the performance of a product after it has been approved for use by the general public.
Lawsuits And Disputes. We may disclose your health information if we are ordered to do so by a court that is handling a lawsuit or other dispute. We may also disclose your information in response to a subpoena, discovery request, or other lawful request by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a court order protecting the information from further disclosure.
Law Enforcement. We may disclose your health information to law enforcement officials for the following reasons:
Except for the first two disclosures, the information disclosed to law enforcement officials will be limited to your contact information or physical characteristics.
To Avert A
Serious Threat To Health Or Safety. We may
use your health information or share it with others when necessary to prevent a
serious threat to your health or safety, or the health or safety of another
person or the public. In such cases, we will only share your information with
someone able to help prevent the threat. We may also disclose your health
information to law enforcement officers if you tell us that you participated in
a violent crime that may have caused serious physical harm to another person
(unless you admitted that fact while in counseling), or if we determine that
you escaped from lawful custody (such as a prison or mental health
National Security And Intelligence Activities Or Protective Services. We may disclose your health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials.
Military And Veterans. If you are in the Armed Forces, we may disclose health information about you to appropriate military command authorities for activities they deem necessary to carry out their military mission. We may also release health information about foreign military personnel to the appropriate foreign military authority.
Inmates And Correctional Institutions. If you are an inmate or you are detained by a law enforcement officer, we may disclose your health information to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security, and good order at the place where you are confined. This includes sharing information that is necessary to protect the health and safety of other inmates or persons involved in supervising or transporting inmates or detainees.† In most situations, the information disclosed will be limited to your contact information or physical characteristics.†
Workers' Compensation. We may disclose your health information for workers' compensation or similar programs that provide benefits for work-related injuries.
Coroners, Medical Examiners And Funeral Directors. In the unfortunate event of your death, we may disclose your health information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release this information to funeral directors as necessary to carry out their duties
Organ And Tissue Donation. In the unfortunate event of your death, we may disclose your health information to organizations that procure or store organs, eyes, or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws.
Research. In most cases, we will ask for your written authorization before using your health information or sharing it with others in order to conduct research. However, under some circumstances, we may use and disclose your health information without your authorization if we obtain approval through a special process to ensure that research without your authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. We may also release your health information without your authorization to people who are preparing a future research project, so long as any information identifying you does not leave our offices. In the unfortunate event of your death, we may share your health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our offices any information that identifies you.
4.† Other Uses and Disclosures
Communications Regarding Our Programs or Products.† We may use and disclose your health information to make a communication to you to describe a health-related product or service of ours.† In addition, we may use or disclose your health information to tell you about products or services related to your treatment, case management or care coordination, or alternative treatments, therapies, providers or settings of care for you. We may occasionally tell you about another company's products or services, but will use or disclose your health information for such communications only if they occur in person with you.† We may also use and disclose your health information to give you a promotional gift from us that is a minimal value.
Incidental Uses and Disclosures.† We may occasionally inadvertently use or disclose your health information when such use or disclosure is incident to another use or disclosure that is permitted or required by law.† For example, while we have safeguards in place to protect against others overhearing our conversations that take place between doctors, nurses or other personnel, there may be times that such conversations are in fact overheard.† Please be assured, however, that we have appropriate safeguards in place to avoid such situations, and others, as much as possible.
Disclosures to You.† Upon a request by you, we may use or disclose your health information in accordance with your request.
Limited Data Sets.† We may use or disclose certain parts of your health information, called a "limited data set," for purposes of research, public health reasons or for our health care operations.† We would disclose a limited data set only to third parties who have provided us with satisfactory assurances that they will use or disclose your health information only for limited purposes.
Disclosures to the Secretary of Health and Human Services.† We might be required by law to disclose your health information to the Secretary of the Department of Health and Human Services, or his/her designee, in the case of a compliance review to determine whether we are complying with privacy laws.
De-Identified Information.† We may use your health information, or disclose it to a third party whom we have hired, to create information that does not identify you in any way.† Once we have de-identified your information, it can be used or disclosed in any way according to law.
Disclosures by Members of Our Workforce.† Members of our workforce, including employees, volunteers, trainees or independent contractors, may disclose your health information to a health oversight agency, public health authority, health care accreditation organization or attorney hired by the workforce member, to report the workforce member's belief that we have engaged in unlawful conduct or that our care or services could endanger a patient, workers or the public.† In addition, if a workforce member is a crime victim, the member may disclose your medical information to a law enforcement official.
Disclosures of Records Containing Drug or Alcohol Abuse Information.† Because of federal law, we will not release your health information if it contains information about drug or alcohol abuse without your written permission except in very limited situations.
Disclosures of Medical Information of Minors.† Under Indiana law, we cannot disclose the health information of minors to non-custodial parents if a court order or decree is in place that prohibits the non-custodial parent from receiving such information.† However, we must have documentation of the court order prior to denying the non-custodial parent such access.
Disclosures of Mental Health Records.† If your records contain information regarding your mental health, we are restricted in the ways that we can use and disclose them.† We can disclose such records without written permission only in the following situations:
® If the disclosure is made to you (unless it is determined by a physician that the release would be detrimental to your health);
® Disclosures to our employees in certain circumstances;
® For payment purposes;
® For data collection, research, and monitoring managed care providers if the disclosure is made to the division of mental health;
® For law enforcement purposes or to avert a serious threat to the health and safety of you or others;
® To a coroner or medical examiner;
® To satisfy reporting requirements;
® To satisfy release of information requirements that are required by law;
® To another provider in an emergency;
® For legitimate business purposes;
® †Under a court order;
® To the Secret Service if necessary to protect a person under Secret Service protection; and
® To the Statewide waiver ombudsman.†
Other Uses of Health Information.† Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written authorization.† If you provide us authorization to use or disclose your health information, you may revoke that authorization, in writing, at any time.† If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. †You understand that we are unable to take back any disclosures we have already made under the authorization, and that we are required to retain our records of the care that we provided to you.
YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION
We want you to know that you have the following rights to access and control your health information. These rights are important because they will help you make sure that the health information we have about you is accurate. They may also help you control the way we use your information and share it with others, or the way we communicate with you about your medical matters.
1. Right To Inspect And Copy Records
You have the right to inspect and obtain a copy of any of your health information that may be used to make decisions about you and your treatment for as long as we maintain this information in our records. This includes medical and billing records. To inspect or obtain a copy of your health information, please submit your request in writing to our Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies we use to fulfill your request.
We ordinarily will respond to your request within 30 days if the information is located in our facility, and within 60 days if it is located off-site at another facility. If we need additional time to respond, we will notify you in writing within the time frame above to explain the reason for the delay and when you can expect to have a final answer to your request.
Under certain very limited circumstances, we may deny your request to inspect or obtain a copy of your information. If we deny part or all of your request, we will provide a written denial that explains our reasons for doing so, and a complete description of your rights to have that decision reviewed and how you can exercise those rights. We will also include information on how to file a complaint about these issues with us or with the Secretary of the Department of Health and Human Services. If we have reason to deny only part of your request, we will provide complete access to the remaining parts after excluding the information we cannot let you inspect or copy.
2. Right To Amend Records
If you believe that the health information we have 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 in our records. To request an amendment, please write to our Privacy Officer. Your request should include the reasons why you think we should make the amendment. Ordinarily we will respond to your request within 60 days. If we need additional time to respond, we will notify you in writing within 60 days to explain the reason for the delay and when you can expect to have a final answer to your request.
If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. For example, if you disagree with our decision, you will have an opportunity to submit a statement explaining your disagreement which we will include in your records. We will also include information on how to file a complaint with us or with the Secretary of the Department of Health and Human Services. These procedures will be explained in more detail in any written denial notice we send you.
3. Right To An Accounting Of Disclosures
After April 14, 2003, you have a right to request an "accounting of disclosures" which is a list with information about how we have shared your information with others. An accounting list, however, will not include:
request this list, please write to our Privacy Officer at the address given on
page one of this document. Your request must state a time period for the
disclosures you want us to include. For example, you may request a list of the
disclosures that we made between January 1, 2004, and January 1, 2005. You have
a right to one list within every 12 month period for free. However, we may
charge you for the cost of providing any additional lists in that same 12 month
period. We will always notify you of any cost involved so that you may choose
to withdraw or modify your request before any costs are incurred.
Ordinarily we will respond to your request for an accounting list within 60 days. If we need additional time to prepare the accounting list you have requested, we will notify you in writing about the reason for the delay and the date when you can expect to receive the accounting list. In rare cases, we may have to delay providing you with the accounting list without notifying you because a law enforcement official or government agency has asked us to do so.
4. Right To Request Additional Privacy Protections
You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, or run our normal business operations. You may also request that we limit how we disclose information about you to family or friends involved in your care. For example, you could request that we not disclose information about a surgery or therapy you had. To request restrictions, please write to our Privacy Officer. Your request should include (1) what information you want to limit; (2) whether you want to limit how we use the information, how we share it with others, or both; and (3) to whom you want the limits to apply.
We are not required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. However, if we do agree, we will be bound by our agreement unless the information is needed to provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so; in other cases, we will need your permission before we can revoke the restriction.
5. Right To Request Confidential Communications
You have the right to request that we communicate with you about your medical matters in a more confidential way. For example, you may ask that we contact you at home instead of at work. To request more confidential communications, please write to:
††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††† Privacy Officer
††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††† Michiana Anesthesia Care, P.C.
††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††† 605 Portage Avenue
††††††††††††††††††††††† ††††††††††††††††††††††† ††††††††††† South Bend, Indiana† 46616
††††††††††††††††††††††† ††††††††††††††††††††††† †††††††††††
We will not ask you the reason for your request, and we will try to accommodate all reasonable requests. Please specify in your request how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice.† We reserve the right to make the revised Notice effective for health information we already have about you as well as any information we receive in the future.† We will post a copy of the current Notice in a clear and prominent location to which you have access.† The Notice is also available to you upon request.† The Notice will contain on the first page, in the top right-hand corner, the effective date.† In addition, if we revise the Notice, you may request a copy of the current Notice in effect.†††††††††† †