Summary of
NOTICE OF PRIVACY PRACTICES
For C.H. MARTIN COMPANY
This summary briefly describes important information
contained in our Notice of Privacy Practices. We encourage you to
take the time to read the complete Notice, which is attached to
this summary.
Our Notice of Privacy Practices describes how we may
use and disclose your protected health information to carry out
treatment, payment or health care operations and for other purposes
that are permitted or required by law. It also describes your rights
to access and control your protected health information. Your "protected
health information" means any of your written and oral health
information, including your demographic data that can be used to
identify you. This is health information that is created or received
by your health care provider, and that relates to your past, present
or future physical or mental health or condition.
This Notice will let you know about the various ways we use and
disclose your medical information, describe your rights and our
obligations with respect to the use or disclosure of your medical
information. We will also ask that you acknowledge receipt of this
Notice the first time you come to or use any of our facilities,
because the law requires us to make a good faith effort to obtain
your acknowledgment.
We are required by law to:
Make sure that any medical or health information that we have that
identifies you is kept private, and will be used or disclosed only
in accord with our Notice of Privacy Practices and applicable law;
Give you the complete Notice of our legal duties and our privacy
practices; and
Abide by the terms of the Notice of Privacy Practices that is in
effect from time to time.
NOTICE OF PRIVACY PRACTICES
For C. H. Martin Company
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.
If you have any questions about this Notice please contact: our
Privacy Contact who is
Neal Counts at (404) 525-1533
OUR COMMITMENT TO PROTECT YOUR HEALTH INFORMATION
This Notice of Privacy Practices describes how we may use and disclose
your protected health information to carry out treatment, payment
or health care operations and for other purposes that are permitted
or required by law. It also describes your rights to access and
control your protected health information. Your "protected
health information" means any of your written and oral health
information, including your demographic data that can be used to
identify you. This is health information that is created or received
by your health care provider, and that relates to your past, present
or future physical or mental health or condition.
We are strongly committed to protecting your medical information.
We create a medical record about your care because we need the record
to provide you with appropriate treatment and to comply with various
legal requirements. We transmit some medical information about your
care in order to obtain payment for the services you receive, and
we use certain information in our day-to-day operations. This Notice
will let you know about the various ways we use and disclose your
medical information, describe your rights and our obligations with
respect to the use or disclosure of your medical information. We
will also ask that you acknowledge receipt of this Notice the first
time you come to or use any of our facilities, because the law requires
us to make a good faith effort to obtain your acknowledgment.
We are required by law to:
Make sure that any medical or health information that we have that
identifies you is kept private, and will be used or disclosed only
in accord with this Notice of Privacy Practices and applicable law;
Give you this Notice of our legal duties and our privacy practices;
and
Abide by the terms of the Notice of Privacy Practices that is in
effect from time to time.
1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
A. Uses and Disclosures of Protected Health Information
for Treatment, Payment and Healthcare Operations
Your protected health information may be used and disclosed by your
(Orthotist or Prosthetist), our office staff and
others outside of our office who are involved in your care and treatment
for the purpose of providing health care services to you. Your protected
health information may also be used and disclosed to pay your health
care bills and to support the operation of this facility.
Following are examples of the types of uses and disclosures of your
protected health care information that this facility is permitted
to make. We have provided some examples of the types of each use
or disclosure we may make, but not every use or disclosure in any
of the following categories will be listed.
For Treatment: We will use and disclose your protected
health information to provide, coordinate, or manage your health
care and any related treatment. This includes the coordination or
management of your health care with a third party that has already
obtained your permission to have access to your protected health
information. For example, we would disclose your protected health
information, as necessary, to the physician that referred you to
us. We will also disclose protected health information to other
health care providers who may be treating you when we have the necessary
permission from you to disclose your protected health information.
For Payment: Your protected health information
will be used, as needed, to obtain payment for your health care
services. This may include certain activities that your health insurance
plan may undertake before it approves or pays for the health care
services we recommend for you such as; making a determination of
eligibility or coverage for insurance benefits, reviewing services
provided to you for medical necessity, and undertaking utilization
review activities. We may also tell your health plan about an orthotic
or prosthetic device you are going to receive to obtain prior approval
or to determine whether your plan will cover the device.
For Healthcare Operations: We may use or disclose,
as needed, your protected health information in order to support
the business activities of this facility. These activities include,
but are not limited to, quality assessment activities, employee
review activities, legal services, licensing, and conducting or
arranging for other business activities. We may share your protected
health information with third party “business associates”
that perform various activities (e.g., billing, transcription services)
for this facility. Whenever an arrangement between our facility
and our business associate involves the use or disclosure of your
protected health information, we will have a written contract that
contains terms that will protect the privacy of your protected health
information.
Treatment Alternatives: We may use or disclose
your protected health information, as necessary, to provide you
with information about treatment alternatives or other health-related
benefits and services that may be of interest to you.
Appointment Reminders: We may use or disclose your
protected health information, as necessary, to contact you to remind
you of your appointment.
Sign In Sheets: We may use a sign-in sheet at the
registration desk where you will be asked to sign your name. We
may also call you by name in the waiting room when your (Orthotist
or Prosthetist) is ready to see you.
Marketing and Health Related Benefits and Services:
We may also use and disclose your protected health information for
other marketing activities. For example, we may send you information
about products or services that we believe may be beneficial to
you. You may contact our Privacy Contact to request that these materials
not be sent to you.
Sale of the Practice: If we decide
to sell this practice or merge or combine with another practice,
we may share your protected health information with the new owners.
B. Uses and Disclosures of Protected Health Information
Based upon Your Written Authorization
Other uses and disclosures of your protected health information
will be made only with your written authorization, unless otherwise
permitted or required by law as described below. You may revoke
your authorization, at any time, in writing. You understand that
we can not take back any use or disclosure we may have made under
the authorization before we received your written revocation, and
that we are required to maintain a record of the medical care that
has been provided to you. The authorization is a separate document,
and you will have the opportunity to review any authorization before
you sign it. We will not condition your treatment in any way on
whether or not you sign any authorization.
C. Other Permitted and Required Uses and Disclosures
That May Be Made Either With Your Agreement or the Opportunity to
Object
We may use and disclose your protected health information in the
following instances. You have the opportunity to agree or object
to the use or disclosure of all or part of your protected health
information. If you are not present or able to agree or object to
the use or disclosure of the protected health information, then
your (Orthotist or Prosthetist) may, using their
professional judgment, determine whether the disclosure is in your
best interest. In this case, only the protected health information
that is relevant to your health care will be disclosed.
Others Involved in Your Healthcare: Unless you
object, we may disclose to a member of your family, a relative,
a close friend or any other person you identify, orally or in writing,
your protected health information that directly relates to that
person’s involvement in your health care. If you are unable
to agree or object to such a disclosure, we may disclose such information
as necessary if we determine that it is in your best interest based
on our professional judgment. We may use or disclose your protected
health information to notify or assist in notifying a family member,
personal representative or any other person that is responsible
for your care of your location or general condition.
D. Other Permitted and Required Uses and Disclosures That May Be
Made Without Your Authorization or Opportunity to Object
We may use or disclose your protected health information in the
following situations without your authorization or providing you
the opportunity to object.
Required By Law: We may use or disclose your protected
health information to the extent that federal, state or local law
requires the use or disclosure. The use or disclosure will be made
in compliance with the law and will be limited to the relevant requirements
of the law. You will be notified, as required by law, of any such
uses or disclosures.
Public Health: We may disclose your protected health
information for public health activities and purposes to a public
health authority that is permitted by law to collect or receive
the information. The disclosure will be made for the purpose of
controlling disease, injury or disability. A disclosure under this
exception would only be made to somebody in a position to help prevent
the threat to public health
Communicable Diseases: We may disclose your protected
health information, if authorized by law, to a person who may have
been exposed to a communicable disease or may otherwise be at risk
of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health
information to a health oversight agency for activities authorized
by law, such as audits, investigations, and inspections. Oversight
agencies seeking this information include government agencies that
oversee the health care system, government benefit programs, other
government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected
health information to a public health authority that is authorized
by law to receive reports of child abuse or neglect. In addition,
we may disclose your protected health information if we believe
that you have been a victim of abuse, neglect or domestic violence
to the governmental entity or agency authorized to receive such
information. We will only make this disclosure if you agree or when
required or authorized by law. In this case, the disclosure will
be made consistent with the requirements of applicable federal and
state laws.
Military and Veterans: If you are a member of the
military, we may release protected health information about you
as required by military command authorities.
Food and Drug Administration: We may disclose your
protected health information to a person or company required by
the Food and Drug Administration to report adverse events, product
defects or problems, biologic product deviations, track products;
to enable product recalls; to make repairs or replacements, or to
conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose your protected
health information in the course of any judicial or administrative
proceeding, in response to an order of a court or administrative
tribunal (to the extent such disclosure is expressly authorized),
in certain conditions in response to a subpoena, discovery request
or other lawful process.
Law Enforcement: We may also disclose your protected
health information, so long as applicable legal requirements are
met, for law enforcement purposes. These law enforcement purposes
might include (1) legal processes and otherwise required by law,
(2) limited information requests for identification and location
purposes, (3) pertaining to victims of a crime, (4) suspicion that
death has occurred as a result of criminal conduct, (5) in the event
that a crime occurs on the premises of the practice, and (6) medical
emergency (not on the facility’s premises) and it is likely
that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may
disclose your protected health information to a coroner or medical
examiner for identification purposes, determining cause of death
or for the coroner or medical examiner to perform other duties authorized
by law. We may also disclose protected health information to a funeral
director, as authorized by law, in order to permit the funeral director
to carry out their duties. We may disclose such information in reasonable
anticipation of death. Protected health information may be used
and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: Under certain circumstances, we may disclose
your protected health information to researchers when an institutional
review board that has reviewed the research proposal and established
protocols to ensure the privacy of your protected health information
has approved their research.
Criminal Activity: Consistent with applicable federal
and state laws, we may disclose your protected health information,
if we believe that the use or disclosure is necessary to prevent
or lessen a serious and imminent threat to the health or safety
of a person or the public. We may also disclose protected health
information if it is necessary for law enforcement authorities to
identify or apprehend an individual.
Military Activity and National Security: When the
appropriate conditions apply, we may use or disclose protected health
information of individuals who are Armed Forces personnel (1) for
activities deemed necessary by appropriate military command authorities;
(2) for the purpose of a determination by the Department of Veterans
Affairs of your eligibility for benefits, or (3) to foreign military
authority if you are a member of that foreign military services.
We may also disclose your protected health information to authorized
federal officials for conducting national security and intelligence
activities, including for the provision of protective services to
the President or others legally authorized.
Workers’ Compensation: We may disclose your
protected health information as authorized to comply with workers’
compensation laws and other similar legally-established programs
that provide benefits for work-related illnesses and injuries.
Inmates: We may use or disclose your protected
health information if you are an inmate of a correctional facility
and your (Orthotist or Prosthetist) created or received your protected
health information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we
must make disclosures to you and when required by the Secretary
of the Department of Health and Human Services to investigate or
determine our compliance with the requirements of the final rule
on Standards for Privacy of Individually Identifiable Health Information.
2. YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
Following is a statement of your rights with respect to your protected
health information and a brief description of how you may exercise
these rights.
You have the right to inspect and copy your protected health
information. This means you may inspect and obtain a copy
of your protected health information contained in your medical and
billing records and any other records that your (Orthotist
or Prosthetist) uses for making decisions about you, for
as long as we maintain the protected health information.
To inspect and copy your medical information, you must submit a
written request to the Privacy Contact listed on the first and last
pages of this Notice. If you request a copy of your information,
we may charge you a fee for the costs of copying, mailing or other
costs incurred by us in complying with your request.
We may deny your request in limited situations specified in the
law. For example, you may not inspect or copy psychotherapy notes;
or information compiled in reasonable anticipation of, or use in,
a civil, criminal, or administrative action or proceeding, and certain
other specified protected health information defined by law. In
some circumstances, you may have a right to have this decision reviewed.
The person conducting the review will not be the person who initially
denied your request. We will comply with the decision in any review.
Please contact our Privacy Contact if you have questions about access
to your medical record.
You have the right to request a restriction of your protected
health information. This means you may ask us not to use
or disclose any part of your protected health information for the
purposes of treatment, payment or healthcare operations. You may
also request that any part of your protected health information
not be disclosed to family members or friends who may be involved
in your care or for notification purposes as described in this Notice
of Privacy Practices. Your request must state the specific restriction
requested and to whom you want the restriction to apply.
Your (Orthotist or Prosthetist) is not required to agree
to a restriction that you may request. If the (Orthotist
or Prosthetist) believes it is in your best interest to
permit use and disclosure of your protected health information,
your protected health information will not be restricted. If your
(Orthotist or Prosthetist) does agree to the requested
restriction, we may not use or disclose your protected health information
in violation of that restriction unless it is needed to provide
emergency treatment. With this in mind, please discuss any restriction
you wish to request with your (Orthotist or Prosthetist).
You may request a restriction by [describe how patient may
obtain a restriction – ex. Submit request in writing, contacting
Privacy Contact, etc.]
You have the right to request to receive confidential communications
from us by alternative means or at an alternative location.
We will accommodate reasonable requests. We may also condition this
accommodation by asking you for information as to how payment will
be handled or specification of an alternative address or other method
of contact. We will not request an explanation from you as to the
basis for the request. Please make this request in writing to our
Privacy Contact.
You may have the right to have your (Orthotist or Prosthetist)
amend your protected health information. This means you
may request an amendment of your protected health information contained
in your medical and billing records and any other records that your
(Orthotist or Prosthetist) uses for making decisions about you,
for as long as we maintain the protected health information. You
must make your request for amendment in writing to our Privacy Contact,
and provide the reason or reasons that support your request.
We may deny any request that is not in writing or does not state
a reason supporting the request. We may deny your request for an
amendment of any information that:
1. Was not created by us, unless the person that
created the information is no longer available to amend the information;
2. Is not part of the protected health information
kept by or for us;
3. Is not part of the information you would be
permitted to inspect or copy; or
4. Is accurate and complete.
If we deny your request for amendment, we will do so in writing
and explain the basis for the denial. You have the right to file
a written statement of disagreement with us. We may prepare a rebuttal
to your statement and will provide you with a copy of any such rebuttal.
Please contact our Privacy Contact to determine if you have questions
about amending your medical record.
You have the right to receive an accounting of certain disclosures
we have made, if any, of your protected health information.
This right only applies to disclosures for purposes other than treatment,
payment or healthcare operations as described in this Notice of
Privacy Practices. It also excludes disclosures we may have made
to you, to family members or friends involved in your care, or for
notification purposes. You have the right to receive specific information
regarding these disclosures that occurred after April 14, 2003.
The right to receive this information is subject to certain exceptions,
restrictions and limitations. You must submit a written request
for disclosures in writing to the Privacy Contact. You must specify
a time period, which may not be longer than six years and cannot
include any date before April 14, 2003. You may request a shorter
timeframe. Your request should indicate the form in which you want
the list (i.e., on paper, etc). You have the right to one free request
within any 12-month period, but we may charge you for any additional
requests in the same 12-month period. We will notify you about the
charges you will be required to pay, and you are free to withdraw
or modify your request in writing before any charges are incurred.
You have the right to obtain a paper copy
of this notice from us, upon request to our Privacy Contact,
or in person at our office, at any time, even if you have agreed
to accept this notice electronically. You may obtain a copy of this
notice on our website.
3. COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services
if you believe your privacy rights have been violated by us. You
may file a complaint with us by notifying our privacy contact of
your complaint. We will not retaliate against you in any way for
filing a complaint, either with us or with the Secretary.
You may contact our Privacy Contact, Neal
Counts at (404) 525-1533 for further information about the
complaint process.
4. CHANGES TO THIS NOTICE
We reserve the right to change the privacy practices that are described
in this Notice of Privacy Practices. We also reserve the right to
apply these changes retroactively to Protected Health Information
received before the change in privacy practices. You may obtain
a revised Notice of Privacy Practices by calling the office and
requesting a revised copy be sent in the mail, asking for one at
the time of your next appointment, or accessing our website
This notice was published and becomes effective on April
14, 2003.
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