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CPS MEDICAL, INC. NOTICE OF
PRIVACY PRACTICES
PLEASE READ THIS NOTICE
CAREFULLY.
EFFECTIVE April 14, 2003 Our Commitment to Your Privacy
If you have any questions about
this notice, please contact CPS MEDICAL, INC. We may use and disclose your
information in the following ways: 1. Treatment. We may use your identifiable
information to provide supplies and services to you. For example, we ask you
to provide us with such information as body weight, height
, etc. Many of the people who work for us may use or disclose your
identifiable health information in order to provide supplies and services to
you or to assist others in your treatment. Additionally, we may disclose your
identifiable health information to others who may assist in your care, such
as your physician, therapists, spouse, children or parents. 2. Payment. We may use and disclose your
identifiable health information in order to bill and collect payment for the
services and supplies you may receive from us. For example, we may contact
your health insurer to certify that you are eligible for benefits (and for
what range of benefits), and we may provide your insurer with details
regarding your treatment to determine if your insurer will cover, or pay for
your supplies and/or services. We may also use and disclose your identifiable
health information to obtain payment from third parties that may be
responsible for such costs, such as family members. Also, we may use your
identifiable health information to bill you directly for services and
supplies. 3. Health Care
Operations. We may
use and disclose your identifiable health information to operate our
business. As examples of the ways in which we may use and disclose your
health information for our operations, 4. Appointment
Reminders. We may
use and disclose your identifiable health information to contact you and
remind you of visits/deliveries. 5. Health-Related
Benefits and Services.
We may use your identifiable health information to inform you of
health-related benefits or services that may be of interest to you. 6. Release of
Information to Family / Friends. We may release your identifiable health information
to a friend or family member that is helping you pay for your health care, or
who assists in taking care of you. 7. Disclosures
Required By Law. We
will use and disclose your identifiable health information when we are
required to do so by federal, state or local law. Use and Disclosure of Your
Identifiable Health Information in Certain Special Circumstances
1. Public Health
Risk. We may
disclose your identifiable health information to public health authorities
that are authorized by law to collect information for the purpose of: o
Maintaining
vital records, such as births and deaths o
Reporting
child abuse or neglect o
Preventing
or controlling disease, injury or disability o
Notifying
a person regarding a potential exposure to a communicable disease o
Notifying
a person regarding a potential risk for spreading or contracting a disease or
condition o
Reporting
reactions to drugs or problems with products or devices o
Notifying
individuals if a product or device they may be using has been recalled o
Notifying
appropriate government agency(ies)
and authority(ies) regarding the potential abuse or
neglect of an adult patient (including domestic violence); however, we will
only disclose this information if the patient agrees or we are required or
authorized by law to disclose this information. 2. Health Oversight
Activities. We may
disclose your health information to a health oversight agency for activities
authorized by law. Oversight activities can include, for example,
investigations, inspections, audits, surveys, licensure and disciplinary
actions; civil, administrative, and criminal procedures or actions; or other
activities necessary for the government to monitor government programs,
compliance with civil rights laws and the health care system in general. 3. Lawsuits and
Similar Proceedings.
We may use and disclose your identifiable health information in response to a
court or administrative order, if you are involved in a lawsuit or similar
proceeding. We also may disclose your identifiable health in response to a
discovery request, subpoena, or other lawful process by another party
involved in a dispute, but only if we have made an effort to inform you of
the request or to obtain an order protecting the information the party has
requested. 4. Law Enforcement. We may release identifiable
health information if asked to do so by a law enforcement official: o
Regarding
a crime victim in certain situations, if we are unable to obtain the person’s
agreement o
Concerning
a death we believe might have resulted from criminal conduct o
Regarding
criminal conduct in our offices o
In
response to a warrant, summons, court order, subpoena, or similar legal
process o
To
identify/locate a suspect, material witness, fugitive or missing person o
In
an emergency, to report a crime (including the location or victim(s) of the
crime, or the description, identity or location of the perpetrator) 5. Serious Threats
to Health or Safety.
We may use and disclose your identifiable health information when necessary
to reduce or prevent a serious threat to your health and safety or the health
and safety of another individual or the public. Under these circumstances, we
will only make disclosures to a person or organization able to help prevent
the threat. 6. Military. We may disclose your
identifiable health information if you are a member of 7. National
Security. We may
disclose your identifiable health information to federal officials for
intelligence and national security activities authorized by law. We also may
disclose your identifiable health information to federal officials in order
to protect the President, other officials or foreign heads of state, or to
conduct investigations. 8. Inmates. We may disclose your
identifiable health information to correctional institutions or law
enforcement officials if you are an inmate or under the custody of a law
enforcement official. Disclosure for these purposes would be necessary: (a)
for the institution to provide health care services to you, (b) for the
safety and security of the institution, and/or (c) to protect your health and
safety or the health and safety of other individuals. 9. Workers’
Compensation. We
may release your identifiable health information for workers’ compensation
and similar programs. 10. Coroners, Medical
Examiners and Funeral Directors. We may disclose health information to a coroner or
medical examiner. We may also disclose medical information to funeral
directors consistent with applicable law to carry out their duties. 11. Organ Procurement
Organizations.
Consistent with applicable law, We may disclose
health information to organ procurement organizations or entities engaged in
the procurement, banking, or the transportation of organs for the purpose of
tissue donation and transplant. 12. Research. We may disclose information to
researchers when their research has been approved by an Institutional Review
Board or Privacy Board that has reviewed the research proposal and
established protocols to ensure the privacy of your healthcare information. Your Rights Regarding Your
Identifiable Health Information 1. Confidential
Communications.
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. For
instance, you may ask that we contact you at home, rather than work. In order
to request a type of confidential communication, you must make a written
request to us, specifying the requested method of contact or location where
you wish to be contacted. We will accommodate reasonable requests. You
do not need to give a reason for your request. 2. Requesting Restrictions. You have the right to request
a restriction in our use or disclosure of your identifiable health
information for treatment, payment or health care operations. Additionally,
you have the right to request we limit our disclosure of your identifiable
health care information to individuals involved in your care or the payment
for your care, such as family members and friends. We are not required to
agree to your request; however, if we do agree, we are bound by our
agreement except when otherwise required by law, in emergencies, or when the
information is necessary to treat you. In order to request a restriction in
our use or disclosure of your identifiable health information, you must make
your request in writing to us. Your request must describe in clear and
concise fashion: (a) the information you wish restricted; (b) whether you are
requesting to limit our use, disclosure or both; and (c) to whom you want the
limits to apply. 3. Inspection and
Copies.
You have the right to inspect and obtain a copy of the identifiable health
information that may be used to make decisions about you, including patient
medical records and billing records, but not including psychotherapy notes.
You must submit your request in writing to us in order to inspect and/or obtain
a copy of your identifiable health information. We may charge a fee for the
costs of copying, mailing, labor and supplies associated with your request.
We may deny your request to inspect and/or copy in certain limited
circumstances; however, you may request a review of our denial. Reviews will
be conducted by another licensed health care professional chosen by us. 4. Amendment. You may ask us to amend your
health information if you believe it to be incorrect or incomplete, and you
may request an amendment for as long as the information is kept by or for us.
To request an amendment, your request must be made in and submitted to us in
writing. You must provide us with a reason that supports your request for
amendment. We will deny your request if you fail to submit your request (and
the reason supporting your request) in writing. Also, we may deny your
request if you ask us to amend information that is: (a) accurate and correct;
(b) not part of the identifiable health information kept by or for us; (c)
not part of the identifiable health information which you would be permitted
to inspect and copy; (d) not created by us, unless the individual or entity
that created the information is not available to amend the information. 5. Accounting of
Disclosures.
All of our patients have the right to request an “accounting of disclosures.”
An “accounting of disclosures” is a list of certain disclosures we have made
of your identifiable health information. In order to obtain an accounting of
disclosures, you must submit your request in writing to our office. All
requests for an “accounting of disclosures” must state a time period which
may not be longer than six years and may not include dates before April 14,
2003. The first list you request within a 12 month period is free of charge,
but we may charge you for additional lists within the same 12 month period.
We will notify you of the cost involved with additional requests, and you may
withdraw your request before you incur any costs. 6. Right to a Paper
Copy of This Notice.
You are entitled to receive a paper copy of our Notice of Privacy Practices.
You may ask us to give you a copy of this notice at any time. To obtain a
paper copy of this notice, contact our office. 7. Right to File a
Complaint.
If you believe your privacy rights have been violated, you may file a
compliant with us or with the Office of Civil Rights. All complaints must be
in writing. You will not be penalized for filing a complaint. 8. Right to Provide
an Authorization for Other Uses and Disclosures. We will obtain your written
authorization for uses and disclosures that are not identified by this notice
or permitted by applicable law. Any authorization you provide to us regarding
the use and disclosure of your identifiable health information may be revoked
at any time in writing. After you revoke your authorization, we will
no longer use or disclose your identifiable health information for the
reasons described in the authorization. Please note,
we are required to retain records of your care.
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