Notice of Privacy 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.
HealthWorks is
required by law to maintain the privacy of your medical information and to
provide you with notice of its legal duties and privacy practices with respect
to this information. The purpose of
this notice is to provide you with that information.
Any information
that is about your health, the health care you receive, or payment for that
care is considered confidential and protected by HealthWorks. We are required to abide by the terms of the
notice that is currently in effect at the time your medical information is used
or disclosed.
We reserve the right to change the terms of this notice and to make the
new notice provisions effective for all medical information that we maintain. We will post a copy of the current notice in
our office. In addition, each time you
come to HealthWorks for treatment or health care services, you may request a
copy of the current notice in effect.
SECTION A
WE MAY USE AND DISCLOSE
YOUR MEDICAL INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE
OPERATIONS.
The following is a description and example
of the ways in which we may use and disclose your medical information:
Ø
For Treatment: We may provide medical information about you
to health care providers, other HealthWorks personnel, or third parties who are
involved in the provision, management, or coordination of your care. For example:
·
Health Care Professionals: Your medical information will be shared among physicians, nurses, and other
healthcare professionals involved in your care.
·
Appointment Reminders: We may use and disclose medical information
to provide appointment reminders or information about treatment alternatives or
other health-related benefits.
Ø
For Payment: We may use or disclose your medical
information so that we can collect or make payment for health care services you
receive or are going to receive. For
example:
·
Insurance: If you participate in a health insurance
plan, we will disclose necessary information to that plan to obtain
preauthorization, if required, or payment for your care.
We may also disclose your medical
information to another health care provider, a health plan, or a health care
clearinghouse for the payment activities of that entity.
Ø
For Health Care Operations: We may use or disclose your medical
information for our activities and operations.
These uses and disclosures are necessary to run our practice and to make
sure that all of our patients receive quality care. For example:
·
Quality Improvement:
We may use or disclose your medical information to review quality of care or
competence of health care providers.
·
Sale: We may need to disclose your medical
information if we ever sell or transfer our practice.
For quality-related or fraud and abuse
activities, if you have or have had a relationship with another health care
provider, a health plan, or a health care clearinghouse, we may also disclose
your medical information to that entity for those types of health care
operations.
SECTION B
WE MAY USE OR DISCLOSE YOUR
MEDICAL INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION.
I.
The following is a description of ways in
which we may use and disclose your information for which an authorization or an
opportunity to agree or object is not required.
Ø
As Required by Law: We may use or disclose your medical
information to the extent required by law, provided that the use or disclosure complies
with and is limited to the relevant requirements of such law.
Ø
Public Health Activities: To the extent authorized or required by law,
we may disclose your medical information to a public health authority to report
disease or injury as part of a public health investigation or to report child
abuse, adult abuse, or domestic violence.
To the extent authorized or required by the
Food and Drug Administration (FDA), we may disclose your medical information to
a person or organization authorized to report adverse events, track products,
enable product recalls, repairs, replacements, and / or
conduct post marketing surveillance. This means we may disclose to
non-governmental persons information about the quality, safety, and
effectiveness of FDA regulated products and activities.
Ø
Victim of Abuse, Neglect, or Domestic
Violence: If we
believe you have been a victim of abuse, neglect, or domestic violence, we may
disclose your medical information to a government authority. We will make this disclosure if it is
necessary to prevent serious harm to you or other potential victims, if you are
unable to agree due to incapacity, if you agree to the disclosure, or when
required by law.
Ø
Health Oversight Activities: We may disclose your medical information to
a health oversight agency for activities authorized by law. These oversight actives include, but are not
limited to, audits, investigations, inspections, and licensure. These activities are necessary for
appropriate oversight of the health care system, government benefit and
regulatory programs, and compliance with civil rights laws.
Ø
Judicial and Administrative Proceedings:
We may disclose medical information about you as required by a court or
administrative order or under certain circumstances in response to a subpoena,
discovery request, or other legal process.
Ø
Law Enforcement:
We may also release medical information
to law enforcement officials as required by law. Under limited circumstances, we may release your medical
information to report a crime or in response to a court order, grand jury
subpoenas, warrant, or administrative request.
Ø
Descendents: Consistent with applicable law, we may
release medical information to a coroner, medical examiner, or funeral
director.
Ø
Research: If a researcher has obtained the required
waiver from the Institutional Review Board or the Privacy Board, has
demonstrated that the information is necessary to the research, and possesses a
minimal risk of inappropriate use or disclosure, we may use and disclose
medical information about you for research purposes. If a researcher has not obtained the required waiver, we will not
disclose your medical information without your written authorization, other
than in a limited data set as described below.
Ø
Limited Data Set: For purposes of research, public health, or
health care operations, it may be necessary to use or disclose some of your
medical information for activities or to persons to whom we are not otherwise
authorized to give your information. In
this situation, we may use your medical information to create a limited data
set in which certain required direct identifiers (such as your name) have been
removed. We will disclose the
information in the limited data set for these purposes only if we have obtained
satisfactory assurances from the recipient that the recipient will only use or
disclose the information for limited purposes.
Ø
To Avert a Serious Threat to Health or
Safety: We may use and disclose medical information about
you when we believe, in good faith, disclosure is necessary to prevent a
serious threat to your health and safety or to the health and safety of the
public or another person.
Ø
Specialized Government Functions: Medical information may be disclosed for
military and veterans affairs, for national security and intelligence
activities, or for correctional activities.
Ø
Workers’ Compensation: We may disclose medical information about
you as necessary to comply with laws relating to worker’s compensation
or similar programs that are established by the law to provide benefits for
work-related injuries or illnesses without regard to fault.
Ø
Business Associates:
We may disclose your medical information to a person or organization that
performs a function or activity on behalf of HealthWorks that involves the use
or disclosure of protected health information, such as billing services
companies. In addition, no later that
April 4, 2004, if a business associate is not a person or organization that we
are otherwise permitted to disclose medical information to, we will only use or
disclose your information to that person or organization if we have obtained
adequate assurances that the business associate will appropriately safeguard
the information.
Ø
Personal Representative: We may disclose your information to a person
who has the authority, under the law, to act on your behalf in making decisions
related to health care.
II. The following is a description of ways in
which we may disclose your information after we have given you an opportunity
to object. We will
attempt to obtain your permission prior to making a disclosure for these
purposes. This permission may be
oral. If we are unable to obtain your
permission because you are incapacitated or we are unable to reach you, we may
use or disclose some or all of this information, if (1) based on our
professional judgement, use or disclosure is in your best interest or (2) use
or disclosure of this information is consistent with your previously expressed
preference.
Ø
Individuals Involved in Your Care or Payment
for Your Care: We may
release relevant medical information about you to a friend or a family member
who is involved in your medical care.
Ø
Disaster Relief: We may disclose medical information about
you to an entity assisting in a disaster relief effort so that your family can
be notified about your condition, status, and location.
SECTION C
WE
MAY USE OR DISCLOSE YOUR MEDICAL INFORMATION FOR OTHER PURPOSES ONCE WE HAVE
OBTAINED YOUR WRITTEN AUTHORIZATION.
Other uses and
disclosures of medical information not covered by this notice or the laws that
apply to us will be made only with your written authorization. You may revoke this authorization, in
writing, at any time. However, this revocation cannot
apply to information that was released prior to HealthWorks’ receipt of the
revocation, while your original authorization to disclose your information was
in force and valid. In addition, if the authorization was obtained as a
condition of obtaining insurance coverage, the insurer will have a right to
contest a claim under the policy.
SECTION D
YOUR RIGHTS REGARDING
MEDICAL INFORMATION ABOUT YOU.
Ø
Rights and Restrictions: You have the right to request a restriction
or limitation on the medical information we disclose about you for treatment,
payment, or health care operations.
You also have the right to request a limit in the medical information we
disclose about you for notification purposes to someone who is involved in your
care or the payment of your care, like a family member or a friend.
We are not required to
agree to your request. If
we do agree, we will comply with your request unless the information is needed
to provide you emergency treatment.
To request
a restriction, you must make your request in writing to our Privacy
Officer. The requested restriction will
not be effective unless and until it has been reviewed and approved by the
Privacy Officer. For purposes of
ensuring proper documentation, we may require that you make your request using
a form that we give you.
We may terminate an
agreed upon restriction without your consent. In that situation, the restriction will only
apply to protected health information created or received before you were
informed of the termination of the restriction.
Ø
The Right to Receive Confidential
Communications: You have
the right to request that we communicate with you about medical matters in a
certain way or at a certain location.
For example, you can ask that we only contact you at work or by
mail. To request confidential
communications, you must make your request in writing to our Privacy
Officer. We will not ask you the reason
for your request. We will accommodate
all reasonable requests. Your request
must specify how or where you wish to be contacted. To comply with this request, we may ask you to (1) provide
information as to how payment will be handled and (2) specify an alternative
method of contact. For purposes of
ensuring proper documentation, we may require that you make your request using
a form that we give you.
Ø
Right to inspect and copy: You have the right to inspect and obtain a
copy of most of your medical information maintained at HealthWorks. You must submit your request in writing to
our Privacy Officer. For purposes of
ensuring proper documentation, we may require that you make your request using
a form that we give you. If you request
a copy of this information, we may charge you a fee for the costs of copying,
mailing, and other supplies associated with your request.
We may deny your request to inspect and
obtain a copy in certain limited circumstances. If you are denied access, you may have the right to request that
the denial be reviewed. Another
licensed health care professional chosen by HealthWorks will review your
request and the denial. The person
conducting the review will not be the person who denied your request. We will comply with the outcome of the
review.
Ø
Right to Amend: If you feel that medical information we have
about you is incorrect or incomplete, you may ask us to amend the
information. You have the right to
request an amendment as long as the information is kept at HealthWorks. To request an amendment, your request must
be made in writing and submitted to our Privacy Officer. In addition, you must provide a reason that
supports your request. For purposes of
ensuring proper documentation, we may require that you make your request using
a designated form.
We may
deny your request for an amendment if it is not in writing or does not include
a reason to support the request. In
addition, we may deny your request if you ask us to amend information that (1)
was not created by us, (2) is not part of the medical information kept by or
for HealthWorks, (3) is not part of the information which you would be
permitted to inspect and copy, or (4) is accurate and complete.
Ø
Right to an Accounting of Disclosure: You have the right to request an accounting
of certain disclosures. This is a list
of the disclosures we made of medical information about you. You have the right to request an accounting
of certain disclosures by the covered entity that were made after April 14,
2003, and for a period of time less than six years from the date of your
request. To request an accounting, you
must submit a written request to our Privacy Officer. Your request should indicate in what form you want the list (for
example, on paper or electronically).
We will comply with your request within sixty days or we will provide
you with and explanation for the delay.
The first list you request within a twelve month period will be
free. For additional lists, we may
charge your for the costs of providing the list. We will notify you of the cost involved and you may choose to
withdraw or modify your request at that time before any costs are incurred.
The right to an
accounting does not apply to all disclosures.
For example, you do not have a right to an accounting of disclosures
pursuant to an authorization, disclosures to carry out treatment, payment, or
health care operations, or disclosures of a limited data set.
Ø
Right to a Paper Copy of this Notice: You have the right to 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 this notice electronically, you are still
entitled to a paper copy of this notice.
You may review a copy of this notice on our website at
www.healthworksrf.com. To obtain a
paper copy of this notice, you may print one from out website, ask for a copy
at registration when you visit HealthWorks for services, or contact our Privacy
Officer.
Ø
Complaints: If you believe your privacy rights have been
violated, you may file a complaint with HealthWorks or with the Secretary of
the Department of Health and Human Services.
To file a complaint with HealthWorks, you must submit your complaint in
writing to our Privacy Officer at: Privacy Officer 943 Maple Drive Morgantown,
WV 26505
You will not be retaliated against for
filing a complaint.
Ø
Questions? For further information about matters
covered by this notice, you may contact out Privacy Officer at the above
address or by telephone at (304) 599-2515.
HealthWorks Rehab & Fitness
Acknowledgement of Receipt of Notices of Privacy Practices
In general, any
information that is about your health, the health care you receive, or payment
for that care is considered confidential and protected by HealthWorks. We may need to use your protected health
information to carry out treatment, payment, healthcare operations, and / or
for other purposes. Our Notice of
Privacy Practices provides a more complete description of permitted uses and
disclosures.
Please sign below
to acknowledge that you have received a copy of our Notice of Privacy
Practices.
___________________________________________________ _____________
Signature of
patient or patient’s representative
Date
___________________________________________________
Printed name of
patient or patient’s representative:
___________________________________________________
Relationship to
patient:
Please return this
acknowledgement as soon as possible. If
you received this form when you arrived at HealthWorks for service, return this
form in person to the Reception Desk before you leave. If you do not return the form in person you
may return this form by mail to:
Privacy Officer
943 Maple Drive
Morgantown, WV 26505
For Use ONLY by
HealthWorks Representative A good faith effort was made to obtain a written
acknowledgement of receipt of our Notice of Privacy Practices that was
provided to (circle one) the patient / the patient’s representative on
__/__/__. The acknowledgement was not
obtained for the following reason(s) ________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Signature of HealthWorks representative:
____________________________________