Notice of Information Practices
You entrust us with individually identifiable personal health and financial information (referred to as personal health information, in the rest of this notice). You are our best and most important source of information about you.
We may also collect personal information about you from others. For example, we may collect personal health information from other health care providers, employers, educational entities, and the judicial system, insurance companies or other community referral sources or partners.
Examples of Information We May Collect and Maintain Include:
You name, address, telephone number, social security number, date of birth, marital status, income, e-mail address, policy or account number, account balance, policy coverage, premium payment, claims history, medical information, motor vehicle reports, details about your transactions with state or federal agencies.
In the Following Situations, We May Use and/or Disclose Your Personal Health Information Without Your Authorization:
- To provide treatment.
- To obtain payment for treatment
- To evaluate the quality of care that you receive.
- To an insurance authority.
- Performing mandatory licensing and regulatory compliance functions.
- For payment such as using details received from an insurance company to coordinate benefits.
- For health care operations to detect or prevent criminal activity, fraud and material misrepresentation.
- For public health activities such as to prevent or control disease, injury, or disability.
- To health oversight agencies for compliance purposes.
- In response to a court of administrative order.
- In response to a subpoena, discovery request, or other lawful process by another person involved in a dispute.
- For law enforcement purposes.
- To avert a serious threat to health or safety to you, another person, or the public.
- To federal officials for intelligence, counterintelligence, and other national security activities.
- To worker’s compensation or other programs that provide benefits for work-related injuries or illness.Family Practice & Screening Center © 2016
This notice describes how medical and other personal information about you may be used and disclosed. It also describes how you can get access to this information. Please review the notice carefully.
Those who act on our behalf
Agencies who receive your personal information from us are required to keep your personal health information confidential. They are required to use the personal health information only to provide the services we have asked them to provide.
All Other Uses And Disclosures of Personal Information
All other uses and sharing of personal health information, not permitted or required by law, will be made only with your written authorization. You may revoke this authorization in writing. If you do, we will no longer use or share the information for the reasons covered by the authorization unless we have taken prior action based on the authorization. We are unable to withdraw any disclosures we have already made with your authorization.
Your Rights Regarding Your Personal Health Information
- To inspect and obtain a copy of your personal health information. *Copies will be provided for a fee *Inspection may be denied based on documented detrimental therapeutic effect
- To request that we amend your personal health information. *We will consider your request but are not legally bound to accept your amendment.
- To receive details about our sharing of your personal health information. *Your first request (on an annual basis) for an “Accounting of Disclosures” will be free of charge. *subsequent request will be granted for a fee.
- To request special accommodations on how your personal health information is communicated (such as alternate addresses and phones).Security of Personal InformationWe maintain physical, administrative, and technical safeguards to guard your information. We limit employee access to information based on essential job functions.We are required to keep your personal information private. We are providing this notice of your legal duties and privacy practices. We will abide by the terms of this notice as currently in effect.If you believe that your privacy rights have been violated, you may send a written complaint to our office at the address below. You may also write the Secretary of the Department of Health and Human Services. We will not take any action against you for filing the complaint.We reserve the right to change the terms of our notice. We reserve the right to make the new notice apply to all personal information that we maintain. We will send a new notice within 60 days of material change. We will mail it to your last known address or send it to you electronically to the last known e-mail address.
For further information or to file a Complaint: 1021 Executive Drive, Suite 102 Hixson, TN 37343 423-531-3398 firstname.lastname@example.org
Family Practice & Screening Center © 2016