ABILITY PROSTHETICS & ORTHOTICS, INC.
NOTICE OF PRIVACY PRACTICES
Effective January 1st, 2004
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.
This Notice of Privacy Practices is provided to you as a requirement of the
Health Insurance Portability and Accountability Act (HIPAA).
We are strongly committed to protecting your medical information, also referred
to as "Protected Health Information". We create a medical record about your
care because we need the record to provide you with appropriate treatment and
to comply with various legal requirements. We transmit some medical information
about your care in order to obtain payment for the services you receive, and we
use certain information in our day-to-day operations. This Notice will let you
know about the various ways we use and disclose your Protected Health
Information. This Notice describes your rights and our obligations with respect
to the use or disclosure of your Protected Health Information.
ACKNOWLEDGEMENT OF RECEIPT OF THIS
NOTICE
You will be asked to provide a signed acknowledgement
of receipt of this Notice. Our intent is to make you aware of the possible uses
and disclosures of your Protected Health Information and your privacy rights.
The delivery of our services will in no way be conditioned upon your signed acknowledgement.
If you decline to provide a signed acknowledgement, we will continue to provide
your treatment, and will use and disclose your Protected Health Information for
the purposes described in this Notice.
OUR DUTIES TO YOU REGARDING PROTECTED HEALTH
INFORMATION
" Protected health information" is individually
identifiable health information. This information relates to your past,
present, or future physical or mental health or condition and related health
care services; to the past, present or future payment for such health care
services; and includes demographic information such as your age, address or
email address. Ability Prosthetics & Orthotics is required by law to do the
following:
.
Make sure that your Protected Health Information is kept private.
. Give you this Notice of our legal duties and privacy practices related to the
use and disclosure of your Protected Health Information.
. Follow the terms of the Notice currently in effect.
. Describe how we will communicate any changes in this Notice to you.
We reserve the right to change this Notice. Its effective date is at the top of
the first page and at the bottom of the last page. We reserve the right to make
the revised Notice effective for Protected Health Information we already have
about you, as well as any Protected Health Information we create or receive in
the future. You may obtain another Notice of Privacy Practices by asking your
practitioner for a copy at your next appointment, sending a written request for
a copy to the Ability Prosthetics & Orthotics' Privacy Officer at the
address listed below, or sending a request for a copy via email to HIPAA@abilitypo.com.
HOW WE MAY USE OR DISCLOSE YOUR
PROTECTED HEALTH INFORMATION
The following categories describe the different types
of uses and disclosures of your Protected Health Information that we are
permitted or required to make. We have also provided some examples of the types
of uses and disclosures that fall within a category. However, not every use or
disclosure in a category will be listed.
Uses and Disclosures for Treatment,
Payment and Health Care Operations
Treatment
We will use and disclose your Protected Health Information to provide,
coordinate, or manage your health care and any related treatment. This includes
the coordination or management of your health care with a third party. For
example, we would disclose your Protected Health Information, as necessary, to
the physician that referred you to us. We will also disclose Protected Health
Information to other health care providers who may be treating you.
Payment
We may use and disclose your Protected Health Information in order to bill and
obtain payment for health care services provided to you. This may include
certain activities that your health insurance plan may undertake before it
approves or pays for the health care services we recommend for you, such as:
making a determination of eligibility or coverage for insurance benefits,
reviewing services provided to you for medical necessity, and undertaking
utilization review activities. We may also tell your health plan about an
orthotic or prosthetic device you are going to receive to obtain prior approval
or to determine whether your plan will cover the device.
Health Care Operations
We may use or disclose your Protected Health Information in connection with our
business operations. These operations include, but are not limited to, quality
assessment activities, development of clinical guidelines, reviewing the
qualifications and performance of practitioners and other health care
professionals, training activities, legal services and auditing functions,
business planning and development and business management and general administrative
activities of our facilities. We may share your Protected Health Information
with third party "business associates" that perform various activities (e.g.,
collections, transcription services) for our facilities. Whenever an
arrangement between our facility and our business associate involves the use or
disclosure of your Protected Health Information, we will have a written
contract that contains terms that will protect the privacy of your Protected
Health Information.
Treatment Alternatives
We may use or disclose your Protected Health Information to provide you with
information about treatment alternatives or other health-related products and
services that may be of interest to you.
Appointment Reminders
We may use or disclose your Protected Health Information to contact you to
remind you of your appointment.
Sign In Sheets
We may use a sign-in sheet at the registration desk where you will be asked to
sign your name. We may also call you by name in the waiting room when your
practitioner is ready to see you.
Sale of the Practice
If we decide to sell this practice or merge or combine with another practice,
we may share your Protected Health Information with prospective buyers or new
owners.
Other Permitted or Required Uses and
Disclosures Without Written Authorization
Others Involved in Your Health Care
Unless you object, or in the event that you are not present or are
incapacitated or in an emergency, we may disclose to a member of your family, a
relative, a close friend, or any other person that you identify, your Protected
Health Information as it directly relates to that person's involvement in your
health care, or payment for such care. Additionally, we may use or disclose
Protected Health Information to notify or assist in notifying your family
member, your personal representative, or any other person responsible for your
care, of your general condition, status and location. Finally, we may also use
or disclose your Protected Health Information to an entity assisting in
disaster relief efforts so that your family member, your personal
representative or other person responsible for your care can be notified about
your general condition, status and location.
Required By Law
We may use or disclose your Protected Health Information to the extent that the
use or disclosure is required by Federal, State or local law.
Public Health
We may disclose your Protected Health Information for public health activities
to public health authorities who are legally authorized to receive such
information. These activities include, but are not limited to, preventing or
controlling disease, injury or disability; reporting vital events; and
conducting public surveillance, public health investigations, and public health
interventions, including notifying persons who may have been exposed to a
communicable disease or may otherwise be at risk of contracting or spreading a
disease or condition.
Health Oversight
We may disclose Protected Health Information to a
health oversight agency for activities authorized by law, such as audits,
investigations, and inspections; licensure and disciplinary actions; and civil,
administrative and criminal proceedings or actions. Oversight agencies seeking
this information include government agencies that oversee the health care
system, government benefit programs, other government regulatory programs and
compliance with the civil rights laws.
Abuse or Neglect
We may disclose your Protected Health Information to a
public health authority that is authorized by law to receive reports of child
abuse or neglect. In addition, if we believe that you have been a victim of
abuse, neglect or domestic violence, we may disclose your Protected Health
Information to a governmental entity or agency authorized by law to receive
reports of abuse, neglect or domestic violence, including a social service or
protective services agency. We will only make this disclosure if you agree or
when required or authorized by law.
Food and Drug Administration
We may disclose your Protected Health Information to a person or company
required by the Food and Drug Administration to report adverse events, product
defects or problems or biologic product deviations; to track products; to
enable product recalls, repairs or replacements; or to conduct post marketing
surveillance, as required.
Legal Proceedings
We may disclose Protected Health Information about you
in response to an order by a court or administrative tribunal. We may also
disclose Protected Health Information about you in response to a subpoena,
discovery request or other lawful process by a party to a judicial or
administrative proceeding, but only if efforts have been made to notify you
about the subpoena, discovery request or lawful process, or to obtain an order
from the court or administrative tribunal protecting the information requested.
Law Enforcement
We may disclose your Protected Health Information in
response to a court order, a court-ordered subpoena, warrant or summons, or
similar process authorized by law. Also, in response to a request from a law
enforcement official, we may disclose Protected Health Information for the
purpose of identifying or locating a suspect, fugitive, material witness or
missing person; or pertaining to a known or suspected victim of a crime.
Finally, we may disclose Protected Health Information to a law enforcement
official: (1) to report a death that we suspect may be the result of criminal
conduct; (2) to report criminal conduct on our premises; or (3) in the event of
a medical emergency (not on our premises), to report a crime, the location of
the crime or victims, or the identity, description or location of the person
who committed the crime.
Limited Data Sets
We may use or disclose your Protected Health Information as part of a "limited
data set". A limited data set contains information regarding all or a portion
of our patients, with most individual identifiers, except for dates of birth or
dates of service and city, state and zip codes, removed. We may use or
disclosure your Protected Health Information as part of a limited data set for
the purposes of research, public health, accreditation, or for quality or other
health care operations. When we disclose a limited data set to a third party,
we will first obtain a written agreement from that party stipulating that it
will not re-identify the information or contact the individuals.
Research
Under certain circumstances, we may disclose your Protected Health Information
to researchers when their research has been approved by an Institutional Review
Board or a privacy board that has reviewed the research proposal and
established protocols to ensure the privacy of your Protected Health
Information. We may also disclose your Protected Health Information to persons
who are preparing to conduct a research project provided that they do not
remove such information from our premises.
Serious Threat to Health or Safety
We may use and disclose your Protected Health Information if we believe that
the use or disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public. Under certain
circumstances, we may also disclose Protected Health Information if it is
necessary for law enforcement authorities to identify or apprehend an
individual.
Military Activity and National Security
If you are a member of the armed forces, we may release Protected Health
Information about you as required by military command authorities. We may also
release Protected Health Information about foreign military personnel to the
appropriate foreign military authority. Finally, we may release Protected
Health Information about you to authorized federal officials so that they may:
(1) conduct intelligence, counter-intelligence, and other national security
activities authorized by law; or (2) provide protection to the President, other
authorized persons or foreign heads of state, or conduct special
investigations.
Workers' Compensation
We may disclose your Protected Health Information as
authorized to comply with workers' compensation laws and other similar legally
established programs that provide benefits for work-related illnesses and
injuries.
Inmates
If you are an inmate of a correctional institution or under the custody of a
law enforcement official, we may release Protected Health Information about you
to the correctional institution or law enforcement official if necessary: (1)
for provision of health care to you; (2) to protect your health and safety or
the health and safety of others; (3) for law enforcement on the premises of the
correctional institution; or (4) for the administration and maintenance of the
safety and security of the correctional institution.
Parental Access
Some state laws concerning minors permit or require disclosure of Protected
Health Information to parents, guardians, and persons acting in a similar legal
status. We will comply with the applicable law of the state where the treatment
is provided and will make disclosures in accordance with such law.
Uses and Disclosures Upon
Written Authorization
All other uses and disclosures of your Protected Health Information that are
not described above will be made only with your written authorization. You may
revoke your authorization, at any time, in writing. You understand that we
cannot take back any use or disclosure we may have made under the authorization
before we received your written revocation, and that we are required to
maintain a record of the medical care that has been provided to you. The
authorization is a separate document, and you will have the opportunity to
review any authorization before you sign it. With the exception of
research-related treatment, we will not condition your treatment on whether or
not you sign any authorization.
YOUR RIGHTS REGARDING YOUR PROTECTED
HEALTH INFORMATION
Following is a statement of your rights with respect to your Protected Health
Information and a brief description of how you may exercise these rights.
You Have the Right to Inspect and Copy
You may inspect and obtain a copy of your Protected Health Information
contained in your medical and billing records and any other records that Ability
Prosthetics & Orthotics uses for making decisions about you, for as long as
we maintain the Protected Health Information.
To inspect and copy your medical information, you must submit a written request
to the Privacy Official at the office(s) where we have provided you with health
care services, or to the Ability Prosthetics & Orthotics Privacy Officer at
the address listed below. If you request a copy of your information, we may
charge you a fee for the costs of copying, mailing or other costs incurred by
us in complying with your request.
We may deny your request in limited situations. For example, you may not
inspect or copy psychotherapy notes; or information compiled in reasonable
anticipation of, or use in, a civil, criminal, or administrative action or
proceeding; and certain other specified Protected Health Information defined by
law. In some circumstances, you may have a right to have this decision reviewed
by a licensed health care professional. The person conducting the review will
not be the person who initially denied your request. We will comply with the
decision in any review. Please contact the Ability Prosthetics & Orthotics
Privacy Officer at the address listed below if you have questions about access
to your Protected Health Information.
Right to Request Restrictions
You may ask us not to use or disclose any part of your
Protected Health Information for the purposes of treatment, payment or health
care operations. You may also request that any part of your Protected Health
Information not be disclosed to family members, relatives, friends or other
persons who may be involved in your care, or for notification or disaster
relief efforts, as described in this Notice. Your request must state the
specific restriction requested and to whom you want the restriction to apply.
Ability Prosthetics & Orthotics is
not required to agree to a restriction that you may request.
If we do agree to the requested restriction, we may not use or disclose your Protected
Health Information in violation of that restriction unless it is needed to
provide emergency treatment. You may request a restriction by submitting a
written request to the Privacy Official at the office(s) where we have provided
you with health care services, or to the Ability Prosthetics & Orthotics
Privacy Officer at the address listed below.
Right to Request Confidential
Communications
You may request that we communicate with you using
alternative means or at an alternative location. We will not ask you the reason
for your request. We will accommodate reasonable requests, when possible. You
may make this request by submitting a written request to the Privacy Official
at the office(s) where we have provided you with health care services, or to the
Ability Prosthetics & Orthotics Privacy Officer at the address listed
below.
Right to Request Amendment
You may request an amendment of your Protected Health Information contained in
your medical and billing records and any other records that Ability Prosthetics
& Orthotics uses for making decisions about you, for as long as we maintain
the Protected Health Information. You must make your request for amendment in
writing to the Privacy Official at the office(s) where we have provided you
with health care services, or to the Ability Prosthetics & Orthotics Privacy Officer at the address listed below, and provide the reason or reasons
that support your request.
We may deny any request that is not in writing or does not state a reason
supporting the request.
We may deny your request for an amendment of any information that:
1. Was not created by
us, unless the person that created the information is no longer available to
amend the information;
2. Is not part of the
Protected Health Information kept by or for us;
3. Is not part of the
information you would be permitted to inspect or copy; or
4. Is accurate and
complete.
If we deny your request for amendment, we will do so in writing and explain the
basis for the denial. You have the right to file a written statement of
disagreement with us. We may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal. Please contact the Privacy
Official at the office(s) where we have provided you with health care services,
or to the Ability Prosthetics & Orthotics Privacy Officer at the address
listed below.
Right to an Accounting of Disclosures
This right only applies to disclosures for purposes other than treatment,
payment or health care operations as described in this Notice of Privacy
Practices It also excludes disclosures: (1) to you; (2) to your family members,
relatives, friends or other persons who may be involved in your care, or for
notification or disaster relief efforts; (3) for national security or
intelligence purposes; (4) to correctional institutions or law enforcement
officials; (5) that occurred prior to April 13, 2002; (6) made incident to a
permitted or required use or disclosure, as described in this Notice; and (7)
made pursuant to an authorization. The right to receive an accounting of
disclosures is subject to certain other exceptions, restrictions and
limitations. You must submit a written request for disclosures in writing to
the Privacy Official at the office(s) where we have provided you with health
care services, or to the Ability Prosthetics & Orthotics Privacy Officer at
the address listed below. You must specify a time period, which may not be
longer than six years from the date of the request and cannot include any date
before January 1st, 2004. You may request a shorter timeframe. Your request
should indicate the form in which you want the list (i.e., on paper, etc). You
have the right to one free request within any 12-month period, but we may
charge you for any additional requests in the same 12-month period. We will
notify you about the charges you will be required to pay, and you are free to
withdraw or modify your request in writing before any charges are incurred.
Right to Obtain a Paper Copy of this
Notice
You have the right to a paper copy of this Notice.
Even if you have agreed to receive this Notice electronically, you are still
entitled to a paper copy of this Notice. You may obtain a paper copy of this
Notice by asking your practitioner for a copy at your next appointment, sending
a written request for a paper copy to the Ability Prosthetics & Orthotics
Privacy Officer at the address listed below, or sending a request for a paper
copy via email to HIPAA@abilitypo.com.
COMPLAINTS
You may complain to us or to the Secretary of the U.
S. Department of Health and Human Services if you believe your privacy rights
have been violated by us.
You may file a complaint with us by writing or phoning the Ability Prosthetics
& Orthotics Privacy Officer.
Ability Prosthetics & Orthotics, Inc.
Attn: HIPAA Privacy Officer
455 S. Washington Street, Suite 11
Gettysburg, PA
17325
Phone: 1-717-337-2273
Email: HIPAA@abilitypo.com
You may contact the Ability Prosthetics &
Orthotics Privacy Officer for further information about the complaint process
or for additional information about any of the other matters identified in this
Notice.
We will not retaliate against you in any way for filing a complaint, either
with us or with the Secretary.
This Notice is effective in its entirety as of January 1st, 2004.
