Notice of Privacy Practices
Notice of Privacy Practices
Eastside Endocrine, P.C.
Privacy Officer - Telephone (770)
Effective Date: August 1, 2003
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.
We understand the importance of privacy and
are committed to maintaining the confidentiality of your medical information. We
make a record of the medical care we provide and may receive such records from
others. We use these records to provide or enable other health care providers to
provide quality medical care, to obtain payment for services provided to you as
allowed by your health plan and to enable us to meet our professional and legal
obligations to operate this medical practice properly. We are required by law to
maintain the privacy of protected health information and to provide individuals
with notice of our legal duties and privacy practices with respect to protected
health information. This notice describes how we may use and disclose your medical
information. It also describes your rights and our legal obligations with respect
to your medical information. If you have any questions about this Notice, please
contact our Privacy Officer listed above.
A. How this Medical Practice May Use or
Disclose Your Health Information ……... p. 1
B. When This Medical Practice May Not Use or
Disclose Your Health Information p. 3
C. Your Health Information Rights
1. Right to Request Special Privacy
2. Right to Request Confidential
3. Right to Inspect and Copy
4. Right to Amend or Supplement
5. Right to an Accounting of
6. Right to a Paper Copy of this
D. Changes to this Notice of Privacy Practices
A. How this Medical Practice May Use or
Disclose Your Health Information
This medical practice collects health
information about you and stores it in a chart and on a computer. This is your
medical record. The medical record is the property of this medical practice, but
the information in the medical record belongs to you. The law permits us to use or
disclose your health information for the following purposes:
1. Treatment. We use medical
information about you to provide your medical care. We disclose medical
information to our employees and others who are involved in providing the care you
need. For example, we may share your medical information with other physicians, or
other health care providers who will provide services which we do not provide. Or
we may share this information with a pharmacist who needs it to dispense a
prescription to you, or a laboratory that performs a test. We may also disclose
medical information to members of your family or others who can help you when you
are sick or injured.
2. Payment. We use and
disclose medical information about you to obtain payment for the services we
provide. For example, we give your health plan the information it requires before
it will pay us. We may also disclose information to other health care providers to
assist them in obtaining payment for services they have provided to you.
3. Health Care Operations. We
may use and disclose medical information about you to operate this medical
practice. For example, we may use and disclose this information to review and
improve the quality of care we provide, or the competence and qualifications of our
professional staff. Or we may use and disclose this information to get your health
plan to authorize services or referrals. We may also use and disclose this
information as necessary for medical reviews, legal services and audits, including
fraud and abuse detection and compliance programs and business planning and
management. We may also share your medical information with our "business
associates,” such as our billing service, that perform administrative
services for us. We have a written contract with each of these business associates
that contains terms requiring them to protect the confidentiality of your medical
information. We may also share your information with other health care providers,
health care clearinghouses or health plans that have a relationship with you, when
they request this information to help them with their quality assessment and
improvement activities, their efforts to improve health or reduce health care
costs, their review of competence, qualifications and performance of health care
professionals, their training programs, their accreditation, certification or
licensing activities, or their health care fraud and abuse detection and compliance
4. Appointment Reminders. We
may use and disclose medical information to contact and remind you about
appointments. If you are not home, we may leave this information on your answering
machine or in a message left with the person answering the phone.
5. Sign in sheet. We may use
and disclose medical information about you by having you sign in when you arrive at
our office. We may also call out your name when we are ready to see you.
6. Notification and communication with family. We may disclose your health information to notify or
assist in notifying a family member, your personal representative or another person
responsible for your care about your location, your general condition or in the
event of your death. In the event of a disaster, we may disclose information to a
relief organization so that they may coordinate these notification efforts. We may
also disclose information to someone who is involved with your care or helps pay
for your care. If you are able and available to agree or object, we will give you
the opportunity to object prior to making these disclosures, although we may
disclose this information in a disaster even over your objection if we believe it
is necessary to respond to the emergency circumstances. If you are unable or
unavailable to agree or object, our health professionals will use their best
judgment in communication with your family and others.
7. Marketing. We may contact
you to give you information about products or services related to your treatment,
case management or care coordination, or to direct or recommend other treatments or
health-related benefits and services that may be of interest to you, or to provide
you with small gifts. We may also encourage you to purchase a product or service
when we see you. We will not use or disclose your medical information without your
8. Required by law. As
required by law, we will use and disclose your health information, but we will
limit our use or disclosure to the relevant requirements of the law. When the law
requires us to report abuse, neglect or domestic violence, or respond to judicial
or administrative proceedings, or to law enforcement officials, we will further
comply with the requirement set forth below concerning those activities.
9. Public health. We may, and
are sometimes required by law to disclose your health information to public health
authorities for purposes related to: preventing or controlling disease, injury or
disability; reporting child, elder or dependent adult abuse or neglect; reporting
domestic violence; reporting to the Food and Drug Administration problems with
products and reactions to medications; and reporting disease or infection
exposure. When we report suspected elder or dependent adult abuse or domestic
violence, we will inform you or your personal representative promptly unless in our
best professional judgment, we believe the notification would place you at risk of
serious harm or would require informing a personal representative we believe is
responsible for the abuse or harm.
10. Health oversight activities. We may, and are sometimes required by law to disclose your health
information to health oversight agencies during the course of audits,
investigations, inspections, licensure and other proceedings, subject to the
limitations imposed by federal and Georgia law.
11. Judicial and administrative proceedings. We may, and are sometimes required by law, to
disclose your health information in the course of any administrative or judicial
proceeding to the extent expressly authorized by a court or administrative order.
We may also disclose information about you in response to a subpoena, discovery
request or other lawful process if reasonable efforts have been made to notify you
of the request and you have not objected, or if your objections have been resolved
by a court or administrative order.
12. Law enforcement. We may,
and are sometimes required by law, to disclose your health information to a law
enforcement official for purposes such as identifying of locating a suspect,
fugitive, material witness or missing person, complying with a court order,
warrant, grand jury subpoena and other law enforcement purposes.
13. Coroners. We may, and are
often required by law, to disclose your health information to coroners in
connection with their investigations of deaths.
14. Organ or tissue donation.
We may disclose your health information to organizations involved in procuring,
banking or transplanting organs and tissues.
15. Public safety. We may, and
are sometimes required by law, to disclose your health information to appropriate
persons in order to prevent or lessen a serious and imminent threat to the health
or safety of a particular person or the general public.
16. Specialized government functions. We may disclose your health information for military or national security
purposes or to correctional institutions or law enforcement officers that have you
in their lawful custody.
17. Worker’s compensation. We may disclose your health information as necessary to comply with
worker’s compensation laws. For example, to the extent your care is covered
by workers' compensation, we will make periodic reports to your employer about your
condition. We are also required by law to report cases of occupational injury or
occupational illness to the employer or workers' compensation insurer.
18. Change of Ownership. In the
event that this medical practice is sold or merged with another organization, your
health information/record will become the property of the new owner, although you
will maintain the right to request that copies of your health information be
transferred to another physician or medical group.
19. Research. We may disclose
your health information to researchers conducting research with respect to which
your written authorization is not required as approved by an Institutional Review
Board or privacy board, in compliance with governing law.]
20. Fundraising. We may use or
disclose your demographic information and the dates that you received treatment in
order to contact you for fundraising activities. If you do not want to receive
these materials, notify the Privacy Officer listed at the top of this Notice of
B. When This Medical Practice May Not
Use or Disclose Your Health Information
Except as described in this Notice of Privacy
Practices, this medical practice will not use or disclose health information which
identifies you without your written authorization. If you do authorize this
medical practice to use or disclose your health information for another purpose,
you may revoke your authorization in writing at any time.
C. Your Health Information
1. Right to Request Special Privacy Protections. You have the right to request restrictions on certain
uses and disclosures of your health information, by a written request specifying
what information you want to limit and what limitations on our use or disclosure of
that information you wish to have imposed. We reserve the right to accept or
reject your request, and will notify you of our decision.
2. Right to Request Confidential Communications. You have the right to request that you receive your
health information in a specific way or at a specific location. For example, you
may ask that we send information to a particular e-mail account or to your work
address. We will comply with all reasonable requests submitted in writing which
specify how or where you wish to receive these communications.
3. Right to Inspect and Copy.
You have the right to inspect and copy your health information, with limited
exceptions. To access your medical information, you must submit a written request
detailing what information you want access to and whether you want to inspect it or
get a copy of it. We will charge a reasonable fee, as allowed by Georgia law. We
may deny your request under limited circumstances. If we deny your request to
access your child's records because we believe allowing access would be reasonably
likely to cause substantial harm to your child, you will have a right to appeal our
decision. If we deny your request to access your psychotherapy notes, you will
have the right to have them transferred to another mental health
4. Right to Amend or Supplement. You have a right to request that we amend your health information that you
believe is incorrect or incomplete. You must make a request to amend in writing,
and include the reasons you believe the information is inaccurate or incomplete.
We are not required to change your health information, and will provide you with
information about this medical practice's denial and how you can disagree with the
denial. We may deny your request if we do not have the information, if we did not
create the information (unless the person or entity that created the information is
no longer available to make the amendment), if you would not be permitted to
inspect or copy the information at issue, or if the information is accurate and
complete as is. You also have the right to request that we add to your record a
statement of up to 250 words concerning any statement or item you believe to be
incomplete or incorrect.
5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health
information made by this medical practice, except that this medical practice does
not have to account for the disclosures provided to you or pursuant to your written
authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health
care operations), 6 (notification and communication with family) and 16
(specialized government functions) of Section A of this Notice of Privacy Practices
or disclosures for purposes of research or public health which exclude direct
patient identifiers, or which are incident to a use or disclosure otherwise
permitted or authorized by law, or the disclosures to a health oversight agency or
law enforcement official to the extent this medical practice has received notice
from that agency or official that providing this accounting would be reasonably
likely to impede their activities.
6. You have a right to a paper copy of this
Notice of Privacy Practices, even if you have previously requested its receipt by
If you would like to have a more detailed
explanation of these rights or if you would like to exercise one or more of these
rights, contact our Privacy Officer listed at the top of this Notice of Privacy
D. Changes to this Notice of Privacy
We reserve the right to amend this Notice of
Privacy Practices at any time in the future. Until such amendment is made, we are
required by law to comply with this Notice. After an amendment is made, the
revised Notice of Privacy Protections will apply to all protected health
information that we maintain, regardless of when it was created or received. We
will keep a copy of the current notice posted in our reception area, and will offer
you a copy at each appointment.
Complaints about this Notice of Privacy
Practices or how this medical practice handles your health information should be
directed to our Privacy Officer listed at the top of this Notice of Privacy
If you are not satisfied with the manner in
which this office handles a complaint, you may submit a formal complaint to:
Department of Health and Human Services,
Office of Civil Rights
You will not be penalized for filing a
Complaints submitted to the DHHS Office for
Civil Rights should be directed to:
Office for Civil Rights/U.S. Department of
Health & Human Services
61 Forsyth Street, SW. - Suite 3B70/Atlanta, GA 30323
(404) 562-7886; (404) 331-2867 (TDD)
(404) 562-7881 FAX