Understanding Your Medical Record Information

Each time you visit or have significant contact with a hospital, doctor or other health care provider, a record of your visit is made. Typically, this record contains information about your symptoms, results of your physical examination and diagnostic tests, an assessment of your current medical condition, and a plan for future care or treatment. This information, often referred to as your medical record, is considered “protected health information” (PHI) and serves as a basis for planning and documenting your care and treatment and provides a means of communication among the many health care professionals who contribute to your care.

The medical record is also a legal document that describes the care you received and is the means by which you or your insurance carrier can verify that the services billed were actually provided. The medical record may also be utilized by public health officials charged with improving the overall health of the community.

Examples of Uses and Disclosures of PHI for Treatment,
Payment and Health Care Operations

We request that you sign a one-time General Consent for Treatment form which allows the organization to use or disclose you health information for purposes relating to treatment, payment or health care operations as described below.

We will use your health information for treatment. For example: Information obtained by our office or other members of your health care team will be recorded in your medical record and will be used to determine the appropriate course of treatment for your particular medical problems or concerns. Your medical record here will contain entries from us, but may also include copies of results from tests performed and correspondence from other health care professionals who have been treating you as long as you have authorized those providers to send information to us. This will result in a more accurate and complete picture of your medical condition so that we will be better able to safely treat your medical problems.

We will use your health information for payment. Following your treatment, a bill for services rendered is sent to you or your insurance company. The information on the bill may include information that identifies you, as well as your diagnosis, procedures performed and any medications or supplies that were used.

Business Associates. There are some services provided in our practice through contracts with business associates to assist us in various aspects of healthcare administration. When these services are contracted, we may disclose your health information so that they can perform the job we have asked them to do. To protect your health information, however, every business associate is contractually obligated to protect your information.

Notifications and reminders. We may contact you by mail or phone to remind you about an upcoming appointment or to inform you about test results.

Funeral Directors. We may disclose health information to funeral directors, consistent with applicable law, to assist them in carrying out their duties

Food and Drug Administration (FDA). We may disclose to the FDA and health information that relates to unusual or adverse events in connection with medications, supplements, or health care equipment in order facilitate medication and/or equipment recalls.

Workers Compensation. We may disclose health information to the extent necessary to comply with laws relating to workers compensation or other similar programs.

Public Health. As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury and disability. Such information may include, but is not limited to, the reporting of abuse or neglect, communicable diseases and reactions to medications or problems with products or devices.

Health oversight activities. We may disclose your health information to a health oversight agency for activities authorized by law.

Law enforcement. We may disclose your health information is asked to do so by a law enforcement official in response to a valid subpoena, search warrant, court order or other similar legal process.

Authorizations

You will be asked to sign an authorization when we are requesting permission to use your PHI for purposes other than treatment, payment or healthcare operations. Examples include disclosing information to an employer for employment decisions or eligibility for life insurance.

Your Rights

Although your medical record belongs to us, the information that it contains belongs to you. You have the right to obtain a paper copy of this document. You have the right to inspect a copy of your medical record. This may exclude certain mental health information (psychotherapy notes). You also have the right to obtain a coy of your medical record. To inspect or get a copy of your medical records you need to submit a request in writing to this office. There may be fees associated with providing copies unless they are going directly to another health care professional. You also have the right to make an addendum or request and amendment to the information in your health record. If you believe that medical information we have about you is incorrect or incomplete, you may provide us a written addendum or amendment to any item or statement in your medical record. This does not apply to information form another medical provider or is accurate and complete as it is. You have the right to revoke your authorization to use or disclose health information at any time except to the extent that the information has already been disclosed. This request should also be made in writing. You have a right to obtain an “accounting of disclosures” of your health information for nonroutine purposes such as disclosures to law enforcement agencies or public health officials. Again, this request should be made in writing. You have the right to request a restriction or limitation on the medical information we use or disclose about you. Additionally, you have the right to request that we restrict our disclosure of medical information to only certain individuals involved in your case. This again needs to be in writing and will be honored except as required by law or in emergencies when the information is necessary to treat you. You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location, such as at home versus at work.

Our responsibility

We are required to maintain the privacy of your health information and must provide you with a notice as to our legal duties and privacy practices with respect to the information we collect and maintain about you. We will not use or disclose your health information except as described in this notice.

EFFECTIVE DATE October 1, 2008