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Notice of Information / Privacy PracticesAs Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR PROTECTED HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
A Breast Pump and More
Effective Date: May 10, 2013
It is important to read and understand this Notice of Privacy Practices before signing the Consent and Acknowledgement Form.
OUR COMMITMENT TO YOUR PRIVACY
We are dedicated to maintaining the privacy of your protected health information. Your protected health information is information about you created and received by us, including demographic information, that may reasonably identify you and that relates to your past, present, or future physical or mental health or condition, or payment for the provision of your health care. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of protected health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy practices concerning your protected health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
To summarize, this notice provides you with the following important information:
How we may use and disclose your protected health information;
Your privacy rights in your protected health information; and
Our obligations concerning the use and disclosure of your protected health information.
The terms of this notice apply to all records containing your protected health information that are created or retained by us. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records we have created or maintained in the past, and for any of your records we may create or maintain in the future. We will post a copy of our current notice on our website, and you may request a copy of our most current notice during any office visit.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
A Breast Pump and More, 1375 S. Acacia Avenue, Fullerton, CA 92831; (866) 688-4203; 1-800-PUMP A MOM; firstname.lastname@example.org.
WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE MANNER NOTED BELOW
The following categories describe the different ways in which we may use and disclose your protected health information:
Treatment. We may use your protected health information to treat you. For example, we may perform a follow-up interview and we may use the results to help us modify your treatment plan. Many of the people who work for us may use of disclose your protected health information in order to treat you or to assist others in your treatment. Additionally, we may disclose your protected health information to others who may assist in your care, such as your physician, therapists, spouse, children, or parents.
Payment. We may use and disclose your protected health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your protected health information to obtain payment from third parties who may be responsible for such costs, such as family members. Also, we may use your protected health information to bill you directly for services and items.
Health Care Operations. We may use and disclose your protected health information to operate our business. For example, we may use your health information to evaluate the quality of care you received from us or to conduct cost-management and business planning activities for us.
Appointment Reminders. We may use and disclose your protected health information to contact you and remind you of visits/deliveries.
Health-Related Benefits and Services. We may use and disclose your protected health information to inform you of health-related benefits or services that may be of interest to you.
Release of Information to Family/Friends. We may release your protected health information to a friend or family member who is helping you pay for your health care of who assists in taking care of you.
Disclosures Required By Law. We will use and disclose your protected health information when we are required to do so by federal, state, or local law.
USE AND DISCLOSURE OF YOUR PROTECTED HEALTH IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your protected health information:
Public Health Risks. We may disclose your protected health information to public health authorities who are authorized by law to collect information for the purpose of:
Maintaining vital records, such as births and deaths.
Reporting child abuse or neglect.
Preventing or controlling disease, injury, or disability.
Notifying a person regarding potential exposure to a communicable disease.
Notifying a person regarding a potential risk for spreading or contracting a disease or condition.
Reporting reactions to drugs or problems with products or devices.
Notifying individuals if a product or device they may be using has been recalled.
Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information.
Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general.
Lawsuits and Similar Proceedings. We may use and disclose your protected health information in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your protected health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
Law Enforcement. We may release protected health information if asked to do so by a law enforcement official:
Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement.
Concerning a death we believe might have resulted from criminal conduct.
Regarding criminal conduct at our offices.
In response to a warrant, summons, court order, subpoena, or similar legal process.
To identify/locate a suspect, material witness, fugitive, or missing person.
In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).
Serious Threats to Health or Safety. We may use and disclose your protected health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
Military. We may disclose your protected health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities.
National Security. We may disclose your protected health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your protected health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
Inmates. We may disclose your protected health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you; (b) for the safety and security of the institution; and/or (c) to protect your health and safety or the health and safety of other individuals.
Workers’ Compensation. We may release your protected health information for workers’ compensation and similar programs.
Business Associate. There may be some services provided by our business associate, such as a billing service or accounting consultants. We may disclose your protected health information to our business associate so that they can perform the job we have asked them to do. To protect your protected health information, we require our business associate to enter into a written contract with requires them to appropriately safeguard your information.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights regarding the protected health information that we maintain about you:
Confidential Communications. You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to A Breast Pump and More, 1375 S. Acacia Avenue, Fullerton, CA 92831 specifying the requested method of contact or the location where you wish to be contacted. We will accommodate reasonable requests. You do not need to give a reason for your request.
Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your protected health information for the treatment, payment, or health care operations. Additionally, you have the right to request that we limit our disclosure of your protected health information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use of disclosure of your protected health information, you must make your request in writing to A Breast Pump and More, 1375 S. Acacia Avenue, Fullerton, CA 92831. Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our use, disclosure, or both; and (c) to whom you want the limits to apply.
Inspection and Copies. You have the right to inspect and obtain a copy of the protected health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing A Breast Pump and More, 1375 S. Acacia Avenue, Fullerton, CA 92831 in order to inspect and/or obtain a copy of your protected health information. We may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Reviews will be conducted by a licensed health care professional. This licensed health care professional will be selected by us.
Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for us. To request an amendment, your request must be made in writing and submitted to A Breast Pump and More, 1375 S. Acacia Avenue, Fullerton, CA 92831. You must provide us with a reason that supports your request for amendment. We will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the protected health information kept by or for us; (c) not part of the health information which you would be permitted to inspect and copy; or (d) not created by us, unless the individual or entity that created the information is not available to amend the information.
Accounting of Disclosures. All of our patients have the right to requests an “accounting of disclosures.” An “accounting of disclosures” is a list of certain disclosures by us has made of your protected health information. In order to obtain an accounting of disclosures, you must submit your request in writing to A Breast Pump and More, 1375 S. Acacia Avenue, Fullerton, CA 92831. All requests for an “accounting of disclosures” must state a time period not to exceed six years and may not include dates prior to April 14, 2003. The first list you request within a 12-month period is free of charge, but we may charge you for additional lists within the same 12-month period. We will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact A Breast Pump and More, 1375 S. Acacia Avenue, Fullerton, CA 92831.
Right 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, A Breast Pump and More, 1375 S. Acacia Avenue, Fullerton, CA 92831. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Right to Provide an Authorization for Other Uses and Disclosures. We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your protected health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your protected health information for the reasons described in the authorization. Please note that we are required to retain records of your care.
Marketing. A signed authorization is required for the use or disclosure of your protected health information for a purpose that encourages you to purchase or use a product or service except for certain limited circumstances such as when the marketing communication is face-to-face or when marketing includes the distribution of a promotion gift of nominal value provided by A Breast Pump and More.