Form Cms-R-131 - Application For Peripheral Neuropathy Treatment (Page 5 of 10) in pdf

full by the patient, the right to have a designated record sent to a third

party, the right to prohibit the sale of your PHI, its use for marketing

Family, Friends and Caregivers

purposes, or participation in research, the right to a disclosure to third

We may share your health information with those you tell us will be

parties given access to your PHI, and the right to complain about a

helping you with your home hygiene, treatment, medications, or

HIPAA violation.

payment. We will be sure to ask your permission first. In the case of an

emergency, where you are unable to tell us what you want we will use

Restrictions, Disclosures to Health Plans, Sale of PHI

our very best judgment when sharing your health information only

You have the right to request certain uses and disclosures of your health

when it will be important to those participating in providing your care.

information. At your request, we may not disclose information about

In the event of death, we are may also may share information with

care you have paid for out-of-pocket to health plans unless for

your family, caregivers, or those involved with payment for care unless

treatment purposes or if the disclosure is required by law. The sale of

there is a written request from you not to do so.

your personal health information is prohibited unless we have a

separate written permission and extends to licenses, lease agreements,

To Coroners, Funeral Directors and Medical

and to the receipt of financial or in kind benefit. It also includes

Examiners

disclosures in conjunction with research if there is any profit margin.

We may be required by law to provide information to coroners, funeral

directors and medical examiners for the purposes of determining a cause

Confidential Communications, e-PHI, Emailing PHI

of death and preparing for a funeral.

You have the right to request that we communicate with you in a

certain way. You may request that we only communicate your health

Medical Research

information privately with no other family members present. We must

Advancing medical knowledge often involves learning from the careful

respond to your written requests for your ePHI within 30 days with a

study of the medical histories of prior patients. Formal review and

one 30 day extension in a mutually agreed electronic form or format if

study of health histories as a part of a research study will happen only

the records are readily reproducible in that format. Hardcopies are

under the ethical guidance, requirements and approval and of an

only permitted when you reject all readily reproducible e-formats. We

Institutional Review Board. Physicians may combine conditioned and

may use unencrypted email for your PHI only if you request that form

unconditioned authorizations if the individual can opt-in to the

of transmission and know that there could be a transmission security

unconditioned research activity. These authorizations may encompass

risk.

future research.

Inspect and Copy Your Health Information

Marketing and Fundraising

You have the right to read, review, and copy your health information,

We are limited in providing third party marketing communications

including your complete chart, x-rays and billing records. If you would

about a product or service to you without a separate written

like a copy of your health information, please let us know. There may

authorization unless we receive no compensation, the communication is

be a reasonable charge to a paper copy and assemble your records, or if

face to face, the communication is a drug or biologic you are currently

electronic, the purchase of portable media such as a cd or memory stick.

being prescribed and the payment is limited to reasonable

reimbursement of the costs of communication, the communication is a

Amend Your Health Information

general not specific health or product promotion, or the

You have the right to ask us to update or modify your records if you

communication involves government–sponsored programs. If we do

believe your health information records are incorrect or incomplete.

any fundraising you may opt out of communications about this.

We will be happy to accommodate you as long as our office maintains

this information. In order to standardize our process, please provide us

Authorization to Use or Disclose Health

with your request in writing and describe your reason for the change.

Information

Your request may be denied if the health information record in question

Other than is stated above or where Federal, State or Local law requires

was not created by our office, is not a part of our records or if the

us, we will not disclose your health information other than with your

records containing your health information are determined to not be

written authorization. You may revoke that authorization in writing at

accurate and complete.

any time.

Documentation of Health Information

Notification of Breach of Security

You have the right to ask us for a description of how and where your

We are required by law to maintain the privacy of your health

health information was used by our office for any reason other than for

information and we are required to report to you if there is a breach of

treatment, payment or health operations. Our documentation

security unless, after completing a risk analysis, it is determined there is a

procedures will enable us to provide information on health information

“low probability of PHI compromise.” We will use the four factors of

usage from April 14, 2003 and forward. Please let us know in writing

risk assessment as outlined by the new privacy rules.

the time period for which you are interested. Thank you for limiting

your request to no more than six years at a time. We may need to

Patient Rights

charge you a reasonable fee for your request.

This law is careful to describe that you have certain rights. This includes

Request a Copy of this Notice

the right to be informed of and control your protected health

information (PHI) including the right to inspect, amend, and obtain an

You have the right to obtain a copy of this Notice of Privacy Practices

electronic copy of your PHI, the right to receive confidential

directly from our office at any time. Stop by or give us a call and we

communications by “alternative means or at alternative locations, the

will mail or email a copy to you.

right to restrictions on disclosures to health plans for treatments paid in

Form Cms-R-131 - Application For Peripheral Neuropathy Treatment Page 5

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