Ketchum
Wood & Burgert, Chartered
d/b/a
Pathology Associates
Notice of Privacy Practices for Protected Health
Information
This notice
describes how medical information about you may be used and disclosed and how
you may obtain access to this information.
If you consent,
KWB Pathology Associates is permitted by federal privacy laws to make use and
disclosure of your health information for purposes of treatment, payment, and
health care operations. Protected health
information is the information we create and obtain in providing our services
to you. Such information may include
documenting your symptoms, examinations and test results, diagnoses, treatment,
and applying for future care or treatment. It also includes billing documents related
to those services.
Examples of uses
of your health information for treatment purposes are:
Ø
During
the course of your specimen processing or upon diagnosis of your pathology
result, the physician determines he/she will need to consult with another
specialist in or out of the area. He/she
will share the information with that specialist and obtain his/her input.
Example of use of your health information for payment purposes:
Ø
We
submit requests for payment to your health insurance company. The health
insurance company (or other business associate helping us obtain payment)
requests information from us regarding medical care given. We will provide
information to them about you and the care given.
Example of Use of Your Information for Health Care Operations:
Ø
We
obtain services from our insurers or other business associates such as quality
assessment, quality improvement, outcome evaluation, protocol and clinical
guidelines development, training programs, credentialing, medical review, legal
services, and insurance. We will share information about you with such insurers
or other business associates as necessary to obtain these services.
Your
Health Information Rights
The health and billing records we maintain are the physical
property of our office. However, the information belongs to you. You have a
right to:
Ø
Request
a restriction on certain uses and disclosures of your health information by
delivering the request in writing to our office. We are not required to grant
the request, but we will comply with any request granted.
Ø
Obtain
a paper copy of this “Notice of Privacy Practices for Protected Health
Information” by making a request at our office.
Ø Request in writing that you be allowed to inspect and copy your health record and billing record.
Ø
Appeal
a denial of access to your protected health information except in certain
circumstances.
Ø
Request
that your health care record be amended to correct incomplete or incorrect
information by delivering a written request to our office. Upon request, we
will provide you with a form to use for this purpose. We are not required to
make such amendments.
Ø
File
a statement of disagreement if your request for amendment is denied. You may
require that copies of the amendment request form and the denial be attached to
all future disclosures of your protected health information.
Ø
Obtain
an accounting of disclosures of your health information as required to be
maintained by law, by delivering a written request to our office. An accounting
will not include internal uses of information for treatment, payment, or
operations, disclosures made to you or made at your request, or disclosures
made to family members or friends in the course of providing care.
Ø
Request
that communications of your health information be made by alternative means or
at an alternative location by delivering the request in writing to our office.
Ø
Revoke
authorizations that you made previously to use or disclose information except
to the extent information or action has already been taken by delivering a
written revocation to our office using the form that we provide.
If you want to exercise any of the above rights, please contact
our Administrator at (850) 878-5143 in person or in writing, during normal
hours. You will be provided with assistance
on the steps to take to exercise your rights.
You have the right to review this Notice before signing the
consent authorizing use and disclosure of your protected health information for
treatment, payment and health care operations purposes.
Pathology
Associates Responsibilities
The office is required to:
Ø
Maintain
the privacy of your health information as required by law.
Ø
Provide
you with a notice as to our duties and privacy practices as related to the
information we collect and maintain about you.
Ø
Abide
by the terms of this Notice.
Ø
Notify
you if we cannot accommodate a requested restriction or request.
Ø
Accommodate
your reasonable requests regarding methods to communicate health
information to you.
We reserve the right to amend, change, or eliminate provisions in
our privacy practices and access practices, and to enact new provisions
regarding the protected health information that we maintain. If our information
practices change, we will amend this Notice. You are entitled to receive a
revised copy of this Notice. You may call to request a copy, or visit our
office to pick up a copy.
To
Request Information or File a Complaint
If you have questions, would like additional information, or want
to report a problem regarding the handling of your information, you may contact
our Administrator at (850) 878-5143.
Additionally, if you believe your privacy rights have been
violated, you may file a written complaint at our office by delivering the
written complaint to our Administrator. You may also file a complaint by
mailing it or e-mailing it to the Secretary of Health and Human Services (
The
Washington
Telephone: 202-619-0257
Toll Free: 1-877-696-6775
Ø
We
cannot, and will not, require you to waive the right to file a complaint with
the Secretary of Health and Human Services (
Ø
We
cannot, and will not, retaliate against you for filing a complaint with
Secretary of Health and Human Services.
Other
Disclosures and Uses
Notification - Unless you
object, we may use or disclose your protected health information to notify, or
assist in notifying a family member, personal representative, or other person
responsible for your care, about your location, and about your general
condition, or your death.
Communication with Family
- Using our best judgment, we may disclose to a family member, other relative,
close personal friend, or any other person you identify, health information
relevant to that person’s involvement in your care or in payment for such care
if you do not object or in an emergency.
Research - We may
disclose information to researchers when their research has been approved by an
institutional review board that has reviewed the research proposal and
established protocols to ensure the privacy of your protected health
information.
Disaster Relief - We may
use and disclose your protected health information to assist in disaster relief
efforts.
Funeral Directors or
Coroners - We may disclose your protected health information to funeral
directors or coroners consistent with applicable law to allow them to carry out
their duties.
Organ Procurement
Organizations - Consistent with applicable law, we may disclose your protected
health information to organ procurement organizations or other entities engaged
in the procurement, banking, or transplantation of organs for the purpose of
tissue donation and transplant.
Food and Drug
Administration (FDA) - If you are seeking compensation through Workers
Compensation, we may disclose your protected health information to the extent
necessary to comply with laws relating to Workers Compensation.
Public Health - As
required by law, we may disclose your protected health information to public
health or legal authorities charged with preventing or controlling disease,
injury, or disability.
Abuse & Neglect - We
may disclose your protected health information to public authorities as allowed
by law to report abuse or neglect.
Correctional Institutions
- If you are an inmate of a correctional institution, we may disclose to the
institution or its agents the protected health information necessary for your
health and the health and safety of other individuals.
Law Enforcement - We may
disclose your protected health information for law enforcement purposes as
required by law, such as when required by a court order, or in cases involving
felony prosecutions, or to the extent an individual is in the custody of law enforcement.
Health Oversight -
Federal law allows us to release your protected health information to
appropriate health oversight agencies or for health oversight activities.
Judicial/Administrative
Proceedings - We may disclose your protected health information in the course
of any judicial or administrative proceeding as allowed or required by law,
with your consent, or as directed by a proper court order.
Serious Threat to Health
or Safety - To avert a serious threat to health or safety, we may disclose your
protected health information consistent with applicable law to prevent or
lessen a serious, imminent threat to the health or safety of a person or the
public.
For Specialized
Governmental Functions - We may disclose your protected health information for
specialized government functions as authorized by law such as to Armed Forces
personnel, for national security purposes, or to public assistance program
personnel.
Other Uses - Other uses
and disclosures besides those identified in this Notice will be made only as
otherwise authorized by law or with written authorization and you may revoke
the authorization as previously provided.
Website - This Notice
will be posted on our website.