Effective Date: October 1, 2020
NOTICE OF PRIVACY PRACTICES
LUZ MEDICINE, PC
This Notice of Privacy Practices describes how Luz Medicine, PC, our Business Associates, and their subcontractors may use and disclose your Protected Health Information (“PHI”) to carry out treatment or health care operations, and for other purposes that are permitted or required by law. It also describes how you can get access to your PHI. PHI is information that identifies you individually, including demographic information that relates your past, present, or future physical or mental health condition and related health care services. Please review it carefully, and if you have any questions please contact us at: 29 Cloister Avenue, Ephrata, PA 17522, Telephone 717-844-9003, and Fax 717-482-9069.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
We understand that PHI about you, your health and the care you receive at Luz Medicine, PC, is personal, and we are committed to protecting it. We may use and disclose your PHI in the following situations:
• Treatment: to provide medical treatment and manage and coordinate your medical care. For example, we may share your medical information with other physicians and health care providers, laboratories, surgery centers, hospitals, case managers, etc. to ensure that the provider has the necessary medical information needed to diagnose and provide treatment to you.
• Health Care Operations: to manage, operate and support our business activities, which may include, but are not limited to, quality assessment, billing and collections, and employee education and review. We may use a sign-in sheet at the registration desk and we may greet you by name. We also may use or disclose your PHI, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related services that may be of interest to you.
• Minors: PHI of minors will be disclosed to their parents/legal guardians, unless prohibited by law.
• As Required by Law: when required by law, for example, to report adverse reactions to medications, report suspected abuse, neglect, or domestic violence, and to prevent or reduce a serious threat to any person’s health or safety.
• Judicial and Administrative Proceedings: for the purposes of responding to, and resolving, disputes, claims and lawsuits, such as in order to respond to a court or administrative order, subpoena, request for discovery, or other legal demand. However, disclosure will only be made if efforts first have been made to inform you of the request or demand. Your PHI also may be disclosed if required for our legal defense in the event of a lawsuit.
• Law Enforcement: for law enforcement purposes when all applicable legal requirements have been met, including, but not limited to, for the purposes of identifying or locating a suspect, fugitive, material witness or missing person, or complying with a court order or warrant.
• Coroners and Medical Examiners: to coroners and medical examiners to assist in the fulfillment of their work responsibilities and investigations.
• Public Health: to address or reduce public health risks, including, but not limited to, reporting to the Food and Drug Administration (FDA) for the purpose of assessing or supporting the quality and safety of an FDA-regulated product or activity, preventing or controlling infectious and other diseases, reporting births and deaths, reporting abuse or neglect, reporting adverse reactions to medications or problems with health products, and providing notification of product recalls.
• Health Oversight Activities: to a health oversight agency for audits, investigations, inspections, licensures, and other similar activities.
• Military, National Security, and other Specialized Government Functions: to authorized officials if you are in the military or involved in national security or intelligence.
• Immunizations: to provide proof of immunization to a school that requires a patient’s immunization record prior to enrollment or admittance of a student if you have agreed to the disclosure.
• Worker’s Compensation: in accordance with workers’ compensation laws, we may report PHI to relevant agencies, tribunals, your employer and your employer’s representative.
• Practice Ownership Change: if Luz Medicine, PC, is sold, acquired or merged with another entity, your PHI will become the property of the new owner, provided that you will retain your right to request copies of your records and have such copies transferred to another physician.
• Breach Notification Purposes: your PHI may be disclosed as a part of a breach notification and reporting process involving your PHI.
• Business Associates: to our Business Associates which provide us with services necessary to operate as a medical practice and which also are legally obligated to comply with applicable privacy laws. We will only provide the minimum information necessary for the Business Associates to perform their functions as it relates to our business operations. For example, we may use a Business Associate to process our billing or transcription.
USES AND DISCLOSURES TO WHICH YOU HAVE THE RIGHT TO OBJECT AND OPT OUT
• Communication with family and/or individuals involved in your care or payment of your care: unless you express your objection, disclosure of your PHI may be made to a family member, friend, or other individual involved in your care, or payment for your care, whom you have identified in writing.
• Disaster Response: in the event of a disaster, your PHI may be disclosed to disaster relief organizations to coordinate your care and/or to notify family members or friends of your location and condition. Whenever feasible, we will provide you with an opportunity to agree or object.
PROTECTED HEALTH INFORMATION AND YOUR RIGHTS
The following are statements of your rights, subject to certain limitations, with respect to your PHI:
• You have the right to inspect and copy your PHI (reasonable fees may apply): Pursuant to your written request, you have the right to inspect and copy your PHI in paper or electronic format. Under federal law, you may not inspect or copy the following types of records: psychotherapy notes, information compiled as it relates to a civil, criminal, or administrative action
or proceeding; information restricted by law; information related to medical research in which you have agreed to participate; information obtained under a promise of confidentiality; and information whose disclosure may result in harm or injury to yourself or others. We have up to 30 days to provide you with the PHI and may charge a reasonable fee for the associated costs.
• You have a right to a summary or explanation of your PHI: You have the right to request only a summary of your PHI if you do not desire to obtain a copy of your entire record. You also have the option to request an explanation of the PHI when you request your entire record.
• You have the right to obtain an electronic copy of medical records: You have the right to request an electronic copy of your medical record either for yourself or to be sent to another individual or organization when your PHI is maintained in an electronic format. We will make every attempt to provide the records in the format you request; however, if the information is not readily accessible or producible in the format you request, we will provide the record in a standard electronic format or a legible hard copy form. Record requests may be subject to a reasonable, cost-based fee for the work required in transmitting the electronic medical records.
• You have the right to receive a notice of breach: In the event of a breach of your unsecured PHI, you have the right to be notified of such breach.
• You have the right to request amendments: At any time if you believe the PHI we have on file for you is inaccurate or incomplete, you may request that we amend the information. Your request for an amendment must be submitted in writing and detail what information is inaccurate and why. Please note that a request for an amendment does not necessarily indicate the information will be amended.
• You have a right to receive an accounting of certain disclosures: You have the right to receive an accounting of disclosures of your PHI. An “accounting” is a list of the disclosures that we have made of your PHI. The request can be made for paper and/or electronic disclosures and will not include disclosures made for the purposes of: treatment; billing and collection; health care operations; notification and communication with family and/or friends; and those required by law.
• You have the right to request restrictions of your PHI: You have a right to restrict and/or limit the PHI we disclose to others, such as family members, friends, and individuals involved in your care or payment for your care. You also have the right to limit or restrict the PHI we use or disclose for treatment, billing and collection, or health care operations. Your request must be submitted in writing and must include the specific restriction requested, to whom you want the restriction to apply, and why you would like to impose the restriction. Please note that we are not required to agree to your request for restriction.
• You have a right to request to receive confidential communications: You have a right to request confidential communications from us by alternative means or at an alternative location. For example, you may designate we send mail only to an address specified by you (which may or may not be your home address). You may indicate we should only call you on your work phone or specify which telephone numbers we are allowed or not allowed to leave messages on. You do not have to disclose the reason for your request; however, you must submit a request with specific instructions in writing.
• You have a right to receive a paper copy of this notice: Even if you have agreed to receive an electronic copy of this Notice of Privacy Practices, you have the right to request that we provide it in paper form. You may make such a request at any time.
CHANGES TO THIS NOTICE
We reserve the right to change the terms of this Notice of Privacy Practices and will notify you of such changes. We also will make copies available of our new notice if you wish to obtain one.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your Protected Health Information. By signing this document, you are acknowledging that you have received a copy of this Notice of Privacy Practices.
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Signature of Patient/Guardian Date