Effective Date of this Notice: April 14, 2003
Cooper Clinic, P.A.
NOTICE OF PRIVACY PRACTICES
As required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR Protected Health Information.PLEASE REVIEW THIS NOTICE CAREFULLY.
OUR
COMMITMENT TO YOUR PRIVACY
Cooper Clinic is dedicated to maintaining the privacy of
your Protected Health Information (PHI). 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 health information
that identifies you. We also are required by law to provide you with this
notice of our legal duties and the privacy practices that we maintain in our
practice concerning your PHI. By federal and state law, we must follow the terms
of the Notice of Privacy Practices that we have in effect at the time.
We realize that these laws are complicated, but we must
provide you with the following important information:
· How we may use and disclose your PHI
· Your privacy rights in your PHI
· Our obligations concerning the use and disclosure
of your PHI
The terms of this notice apply to all records containing
your PHI that are created or retained by our practice. We reserve the right
to revise or amend this Notice of Privacy Practices. Any revision or amendment
to this notice will be effective for all of your records that our practice
has created or maintained in the past, and for any of your records that
we may create or maintain in the future. Our practice will post a copy of the
current Notice in our offices in a visible location at all times, and you
may request a copy of our most current Notice at any time.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Tina Kolb, Privacy Officer, (479) 274-2000, Ext. 2782.
WE MAY USE AND DISCLOSE YOUR Protected Health Information
(PHI) IN THE FOLLOWING WAYS.
The following categories describe the different ways in
which we may use and disclose your PHI.
1. Treatment.
Cooper Clinic may use your PHI to treat you. For example,
we may ask you to have laboratory tests (such as blood or urine tests),
and we may use the results to help us reach a diagnosis. We might use your PHI
in order to write a prescription for you. Many of the people who work for
our practice, including, but not limited to, our doctors and nurses may use or
disclose your PHI in order to treat you or to assist others in your treatment.
Additionally, we may disclose your PHI to others who may assist in your
care, such as your spouse, children, or parents. Finally we may also disclose
your PHI to other health care providers for purposes related to your treatment.
2. Payment.
Cooper Clinic may use and disclose your PHI 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 details regarding your treatment to determine if your insurer will cover,
or pay for, your treatment. We also may use and disclose your PHI to obtain payment
from third parties who may be responsible for such costs. Also, we may
use your PHI to bill you directly for services and items. We may disclose your
PHI to other health care providers and entities to assist in their billing
and collection efforts.
3. Health Care Operations.
Cooper Clinic may use and disclose your PHI to operate our
business. As examples of the ways in which we may use and disclose your
information for our operations, our practice may use your PHI to evaluate the
quality of care you received from us, or to conduct cost management and business
planning activities for our practice. We may disclose your PHI to other health
care providers and entities to assist in their health care operations.
4. Appointment Reminders.
Cooper Clinic may use and disclose your PHI to contact and
remind you of an appointment unless restricted by you on
the Limitations and Restrictions of Protected Health Information.
5. Treatment Options.
Cooper Clinic may use and disclose your PHI to inform you
of
potential treatment options or alternatives, unless restricted
by you on the Limitations and Restrictions of Protected Health Information.
6. Disclosure Required By Law.
Cooper Clinic will use and disclose your PHI when we
are required to do so by federal, state or local law.
USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which
we may use or disclose your Individual Identifiable Health Information.
1. Public Health Risks.
Cooper Clinic may disclose your PHI to Public Health authorities
that 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
2. Health Oversight Activities.
Cooper Clinic may disclose your PHI to a health oversight
agency for activities authorized by law. Oversight activities
may include, for example, investigations, inspections, audits, surveys,
licensure and disciplinary actions; civil, administrative, and criminal procedure
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.
3. Lawsuits and Similar Proceedings.
Cooper Clinic may use and disclose your PHI in response
to a court or administrative order, if you are involved in a lawsuit or
similar proceeding. We also may disclose your PHI in response to a discovery
request, subpoena, or other lawful process by another party involved in the dispute,
but only if we have a made an effort to inform you of the request or to
obtain an order protecting the information the party has requested.
4. Law Enforcement.
Cooper Clinic may release PHI 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 has 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)
5. Deceased Patients.
Cooper Clinic may release PHI to a medical examiner or coroner
to identify a deceased individual or to identify the cause of death. If
necessary, we also may release information in order for funeral directors to
perform their jobs.
6. Organ and Tissue Donation.
Cooper Clinic may release your PHI to organizations that
handle organ, eye or tissue procurement or transplantation, including organ
donation banks, as necessary to facilitate organ or tissue donation and
transplantation if you are an organ donor.
7. Research.
Cooper Clinic may use and disclose your PHI for research
purposes in certain limited circumstances. We will obtain your written
authorization to use your PHI for research purposes except when an Institutional
Review Board or Privacy Board has determined that that waiver of your authorization
satisfies the following: (i) the use or disclosure involves no more than a minimal
risk to the individual's privacy based on the following: (A) an adequate plan
to protect the identifiers from improper use and disclosure; (B) an adequate
plan to destroy the identifiers at the earliest opportunity consistent with the
research (unless there is a health or research justification for retaining
the identifiers or such retention is otherwise required by law): and (C)
adequate written assurances that Personal Health Information will not be re-used
or disclosed to any other person or entity (except as required by law) for authorized
oversight of the research study, or for other research or which the use
or disclosure would otherwise be permitted;(ii) the research could not practicably
be conducted without the waiver; and (iii) the research could not practicably
be conducted without access to and use of the PHI.
8. Serious Threats to Health or Safety.
Cooper Clinic may use and disclose your PHI 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.
9. Military.
Cooper Clinic may disclose your PHI if you are a member
of U.S. or foreign military forces (including veterans) and if required
by the appropriate authorities.
10. National Security.
Cooper Clinic may disclose your PHI to federal officials
for intelligence and national security activities authorized by law. We
also may disclose your PHI to federal officials in order to protect the President,
other officials or foreign heads of state, or to conduct investigations.
11. Inmates.
Cooper Clinic may disclose your PHI to correctional institutions
or law enforcement officials if you are an inmate or under 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.
12. Worker's Compensation.
Cooper Clinic may release your PHI for workers' compensation
and similar programs.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding the PHI that we
maintain about you:
1. Confidential Communications.
You must request in writing a request for Limitations and
Restrictions of Protected Health Information that Cooper Clinic 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 specific type of confidential communication,
you must complete a written request, specifying the requested method of
contact, or location where you wish to be contacted. Our clinic will attempt
to accommodate any reasonable request. Please contact the Medical Record Department
at 479-274-2000, Ext. 1202, to obtain a request form. Send your completed request
form to Cooper Clinic, Attn: Tina Kolb, P.O. Box 3528, Fort Smith, AR 72913.
If you prefer, you may present this request form to the receptionist at the time
of your visit.
2. Requesting Restrictions.
You have the right to request a restriction in our use or
disclosure of your PHI treatment, payment or health care operations. Additionally,
you have the right to request that we restrict our disclosure of your PHI
to only certain individuals involved in your care or the payment for your care,
such as family members, and friends. We are not required to agree with
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 or disclosure
of your PHI, you must make your request in writing to Tina Kolb, Privacy Officer,
P.O. Box 3528, Fort Smith, AR 72913. Your request must describe in a clear
and concise fashion:(a) the information you wish restricted (b) whether
you are requesting to limit our practice's use, disclosure or both; and (c) to
whom you want the limits to apply.
3. Inspection and Copies.
You have the right to inspect and obtain a copy of the PHI
that may be used to make decisions about you, including patient medical
records and billing records, but not including psychotherapy notes. In order
to inspect and/or obtain a copy of your PHI, you must submit your request in
writing to Cooper Clinic Medical Records Department, P.O. Box 3528, 6801 Rogers
Avenue, Fort Smith, AR 72913. There may be a fee for the costs of copying, mailing,
labor and supplies associated with your request. The Clinic may deny your
request to inspect and/or copy in certain limited circumstances; however, you
may request a review of our denial. Another licensed health care professional
chosen by us will conduct the review.
4. 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 our practice. To request an amendment,
your request must be made in writing and submitted to the Medical Records
Department, P.O. Box 3528, 6801 Rogers Avenue, Fort Smith, AR 72913. You must
provide us with a reason that supports your request for amendment. Our practice
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 in our opinion: (a) accurate or complete; (b) not
part of the PHI kept by or for the practice;(c) not part of the PHI which you
would be permitted to inspect and copy; or (d) not created by our practice, unless
the individual or entity that created the information is not available
to amend the information.
5. Accounting of Disclosures.
Patients have the right to request an "accounting of
disclosures." An "accounting of disclosures" is a list of certain
non-routine disclosures our clinic has made of your PHI for non-treatment or
operations purposes. Use of your PHI as part of the routine patient care in
the clinic is not required to be documented. For example, the doctor shares
information with the nurse; or the billing department using your information
to file your insurance claim. In order to obtain an accounting of disclosures,
you must submit your request in writing to Medical Records Department, P.O.
Box 3528, 6801 Rogers Avenue, Fort Smith, AR 72913. All requests for an "accounting
of disclosures" must state a time period, which may not be longer
than six (6) years from the date of disclosure and may not include dates
before April 14, 2003. The first list you request within a 12-month period
is free of charge, but our clinic may charge you for additional lists within
the same 12-month period. Our practice will notify you of the costs involved
with additional requests, and you may withdraw your request before you
incur any costs.
6. 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 the Medical Records
Department, 479-274-2000, Ext. 2640.
7. Right to File a Complaint. If you believe
your privacy rights have been violated, you may file a complaint with the clinic
or with the Secretary of the Department of Health and Human Services. We urge
you file your complaint with us first and give us the opportunity
to address your concerns. All complaints must be submitted in writing to, Tina
Kolb, Privacy Officer, P.O. Box 3528, Fort Smith, AR 72913. You will not be penalized
for filing a complaint.
8. Right to Provide an Authorization for Other Uses and
Disclosures.
Cooper Clinic 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 PHI may be revoked at any time in writing. After you revoke
your authorization, we will no longer use or disclose your PHI for the reasons
described in the authorization. Please note we are required to retain records
of your care.
Again, if you have any questions regarding this notice or
our health information privacy policies, please contact Tina Kolb, Privacy
Officer, (479) 274-2000, Ext. 2782.