PRIVACY STATEMENT

THE DOCTORS’ CLINIC LLP                               January 1, 2003

 

NOTICE OF PRIVACY INFORMATION 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.

 

  1. PURPOSE OF THIS NOTICE.

 

The Doctors’ Clinic is committed to preserving the privacy and confidentiality of your health information which is created and/or maintained at our Clinic.  State and federal laws and regulations require us to implement policies and procedures to safeguard the privacy of your health information.  This Notice will provide you with information concerning our privacy practices and applies to all of your health information created and/or maintained at our Clinic, including any information that we may receive from other health care providers or facilities.  The Notice describes the ways in which we may use or disclose your health information and also describes your rights and our obligations concerning such uses or disclosures.

 

We will abide by the terms of this Notice, including any future revisions that we may make to the Notice as required or authorized by law.  We reserve the right to change this Notice and to make the revised or changed 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, which will identify its effective date, in our Clinic.

 

The privacy practices described in this Notice will be followed by:

 

  1. Any health care professional authorized to enter information into your medical record created and/or maintained at our Clinic;

 

  1. All employees, students, residents, and other service providers who have access to your health information at our Clinic, and

 

  1. Any member of a volunteer group which is allowed to help you while receiving services at our Clinic.

 

The individuals identified above will share your health information with each other for purposes of treatment, payment and health care operations, as further described in the Notice.

 

  1.  USES AND DISCLOSURES OF HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS.

 

Treatment, Payment and Health Care Operations.  The following section describes different ways that we may use and disclose your health information for purposes of treatment, payment, and health care operations.  We explain each of these purposes below and include examples of the types or uses or disclosures that may be made for each purpose.  We have not listed every type of use or disclosure, but the ways in which we use or disclose your information will fall under one of these purposes.

 

1.  Treatment.  We may use your health information to provide you with health care treatment and services.  We may disclose your health information to doctors, nurses, nursing assistants, medication aides, technicians, medical and nursing students, rehabilitation therapy specialists, or other personnel who are involved with your health care.

 

For example, we may order physical therapy service to improve your strength and walking abilities.  We will need to talk with the physical therapist so that we can coordinate services and develop a plan of care.  We also may need to refer you to another health care provider to receive certain services.  We will share information with that health care provider in order to coordinate your care and services.

 

2.  Payment.  We may use or disclose your health information so that we

may bill and receive payment from you, an insurance company, or another third party for the health care services you receive from us.  We may also disclose health information about you to your health plan in order to obtain prior approval for the services we provide to you, or to determine that your health plan will pay for the treatment.

 

For example, we may need to give health information to your health plan in order to obtain prior approval to refer you to a health care specialist, such as a neurologist or orthopedic surgeon, or to perform a diagnostic test such as a magnetic resonance imaging scan (MRI) or a CT scan.

 

3.  Health Care Operations.  We may use or disclose your health information in order to perform the necessary administrative, educational, quality assurance and business functions of our Clinic. 

 

For example, we may use your health information to evaluate the performance of our staff in caring for you.  We also may use your health information to evaluate whether certain treatments or services offered by our Clinic are effective.  We also may disclose your health information to other physicians, nurses, technicians, or health profession students for teaching and learning purposes. 

 

 

                         

  1.  USES AND DISCLOSURES OF HEALTH INFORMATION IN SPECIAL    SITUATIONS.

 

We may use or disclose your health information in certain special situations as described below.  For these situations, you have the right to limit these uses and disclosures as provided for in Section F of this Notice.

 

    1. Appointment reminders.  We may use or disclose you health information for purposes of contacting to remind you of a health care appointment. 

 

    1. Treatment alternatives and Health related products and services.    We may use or disclose you health information for purposes of contacting you to inform you of treatment alternatives or health related products or services that may be of interest to you.  For example, if you are diagnosed with a diabetic condition, we may contact you to inform you of a diabetic instruction class that is being offered.

 

 

    1. Family members and friends.   We may disclose your health information to individuals, such as family members and friends, who are involved in your care or who help pay for your care.  We may make such disclosures when: (a) we have your verbal agreement to do so;  (b) we may such disclosures and you do not object; or (c) we can infer from the circumstances that you would not object to such disclosures.  For example, if your spouse comes into the exam room with you, we will assume that you agree to our disclosure of your information while your spouse is present in the room. 

 

We may also disclose your health information to family members or friends in instances when you unable to agree or object to such disclosures, provided that we feel it is in your best interests to make such disclosures and the disclosures relate to that family member or friend’s involvement in your care.  For example, if you present to our Clinic with an emergency medical condition, we may share information with the family member or friend that comes with you to our Clinic.  We also may share your health information with a family member or friend who calls us to request prescription refill for you. 

 

D.     OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES OF HEALTH INFORMATION. 

 

There are certain instances in which we may be required or permitted by law to use or disclose your health information without your permission.  These instances are as follow:

 

    1. As required by law.  We may disclose your health information when required by federal, state, or local law to do so.  For example, we are required by the Department of Health and Human Services (HHS) to disclose your health information in order to allow HHS to evaluate whether we are in compliance with the federal privacy regulations.

 

    1. Public health activities.  We may disclose you health information to public health authorities that are authorized by law to receive and collect health information for the purpose of preventing or controlling disease, injury or disability, to report births, deaths, suspected abuse or neglect, reactions to medications; or to facilitate product recalls.

 

    1. Health oversight activities.  We may disclose your health information to a health oversight agency that is authorized by law to conduct health oversight activities, including audits, investigations, inspections, or licensure and certification surveys.  These activities are necessary for the government to monitor the persons or organizations that provide health care to individuals and to ensure compliance with applicable state and federal laws and regulations.
    2. Judicial or administrative proceedings.  We may disclose you health information to courts or administrative agencies charged with the authority to hear and resolve lawsuits or disputes.  We may disclose your health information pursuant to a court order, a subpoena, a discovery request, or other lawful process issued by a judge or other person involved in the dispute, but only if efforts have been made to either notify you of the request for disclosure or to obtain an order protecting your health information.

 

    1. Workers’ compensation.  We may disclose your health information to workers’ compensation programs when your health condition arises out of work related illness or injury.

 

    1. Law enforcement official.  We may disclose your health information in response to a request received from a law enforcement official to report criminal activity or to respond to a subpoena, court order, warrant, summons, or similar process.

 

    1. Coroners, medical examiners, or funeral directors.  We may disclose your health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death.  We also may disclose your health information to a funeral director for the purpose of carrying out his/her necessary activities.

 

    1. Organ procurement organizations or tissue banks.  If you are an organ donor, we may disclose your health information to organizations that handle organ procurement, transplantation, or tissue banking for the purpose of facilitating organ or tissue donation or transplantation.

 

    1. Research.  We may use or disclose your health information for research purposes under certain limited circumstances.  Because all research projects are subject to a special approval process, we will not use or disclose your health information for research purposes until the particular research project for which you health information may be used or disclosed has been approved through this special approval process.  However, we may use or disclose your health information to individuals preparing to conduct the research project in order to assist them in identifying patients with specific health care needs who may qualify to participate in the research project.  Any use or disclosure of your health information which is done for the purpose of identifying qualified participants will be conducted onsite at our facility.  In most instances, we will ask for your specific permission to use or disclose your health information if the researcher will have access to your name, address or other identifying information.

 

    1. To avert a serious threat to health or safety.  We may use or disclose your health information when necessary to prevent a serious threat to the health or safety of you or other individuals.

 

    1. Military and veterans.   If you are a member of the armed forces, we may use or disclose you health information as required by military command authorities.
    2. National security and intelligence activities.  We may use or disclose your health information to authorized federal officials for purposes of intelligence, counterintelligence, and other national security activities, as authorized by law.

 

    1. Inmates.  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may use or disclose your health information to the correctional institution or to the law enforcement official as may be necessary (i) for the institution to provide you with health care, (ii) to protect the health or safety of you or another person, or (iii) for the safety and security of the correctional institution. 

 

E.     USES AND DISCLOSURES PURSUANT TO YOUR WRITTEN AUTHORIZATION

 

Except for the purposes identified above in Sections B through D, we will not use or disclose your health information for any other purposes unless we have your specific written authorization.  You have the right to revoke a written authorization at any time as long as you do so in writing.  If you revoke your authorization, we will no longer use or disclose your health information for the purposes identified in the authorization, except to the extent that we have already taken some action in reliance upon your authorization.

 

F.      YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION.

 

You have the following rights regarding your health information.  You may exercise each of these rights, in writing, by providing us with a completed form that you can obtain from Medical Records Department, The Doctors’ Clinic LLP.  In some instances we may charge you for the costs associated with providing you the requested information.  Additional information regarding how to exercise your rights, and the associated costs, can also be obtained from the Medical Records Department, The Doctors’ Clinic LLP.

 

    1. Right to inspect and copy.  You have the right to inspect and copy health information that may be used to make decisions about your care.  We may deny your request to inspect and copy your health information in certain limited circumstances.  If you are denied access to your health information, you may request that the denial be reviewed.

 

    1. Right to amend.  You have the right to request an amendment of your health information that is maintained by or for our Clinic and is used to make health care decisions about you.  We may deny your request if it is not properly submitted or does not include a reason to support your request.  We may also deny your request if the information sought to be amended:  (a) was not created by us, unless the person or entity that created the information is no longer available to make the amendment;  (b) is not part of the information that is kept by or for our Clinic; (c) is not part of the information which you are permitted to inspect and copy; or (d) is accurate and complete.

 

    1. Right to an accounting of disclosures.  You have the right to request an accounting of the disclosures of your health information made by us.  This accounting will include disclosures of health information that we made for purposes of treatment, payment or health care operations or pursuant to a written authorization that you have signed.
    2. Right to request restrictions.  You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations.  You also have the right to request a limit on the health information we disclose about you to someone, such as a family member or friend, who is involved in your care or in the payment for your care.  For example, you could ask that we not use or disclose information regarding a particular treatment that you received.  We are not required to agree to your request.  If we do agree, that agreement must be in writing and signed you and us.

 

    1. Right to request confidential communications.  You have the right to request that we communicate with you about your health care in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail.

 

    1. Right to a paper copy of this Notice.  You have the right to receive a paper copy of this Notice.  You may ask us to give you a copy of this Notice at any time.  Even if you have agreed to receive future editions or revisions to this Notice electronically, you are still entitled to a paper copy of this Notice.

 

 

G.     QUESTIONS OR COMPLAINTS

 

If you have questions about this Notice or wish to receive additional information about our privacy practices, please contact our Privacy Officer at 503-391-1110.  If you believe your privacy rights have been violated, you may file a complaint with our Clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with our Clinic, contact our Privacy Officer at The Doctors’ Clinic LLP, 5050 Skyline Village Loop S., Salem, Oregon 97306.  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.

 

 

 

 

 

 

 

The Doctors’ Clinic LLP

Personal Medical Care

 

 

 

 

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

 

 

 

I, (name of patient) ____________________________________________________________, acknowledge and agree that I have received a copy of The Doctors’ Clinic LLP Notice of Privacy Practices.

 

 

 

_________________________________________                _________________________

Patient Signature                                                                                                Date

 

 

________________________________________________________                       __________________________________

Patient Legal Representative  (if applicable)                                                                      Date

 

 

________________________________________________________                        __________________________________

Print Name of Legal Representative                                                                   Relationship to patient

 

 

 

 

 

 

 

 

FOR CLINIC USE ONLY:

 

The Doctors’ Clinic LLP made the following good faith efforts to obtain the above referenced individual’s written acknowledgement of receipt of the Notice of Privacy Practices.

 

(Identify the efforts that were made to obtain the individual’s written acknowledgement, including the reasons, if known, why the written acknowledgement was not obtained)

 

 

 

 

 

 

 

 

 

 

 

 

                                                                                                __________________________

                                                                                                Signature

 

 

 

 (503) 391-1110

© 2003 The Doctors' Clinic, LLP