This notice describes information practices for employees and business contacts of Beckett Ridge Family Medicine. It also pertains to any students, medical, physician assistant, nursing, medical assistant, or any other student training or shadowing at any of our offices, billing facilities, or laboratory. All of these individuals will be required to follow the terms of this notice. These entities will share medical and other information with each other, and with outside agencies, for treatment, payment or as needed to perform other operations.
We at the Beckett Ridge Family Medicine realize that the information that is gathered about you and your family during an encounter with one of our staff is provided in confidence, and we are committed to keeping that confidence. This notice applies to any information that we have about you regardless of how it is stored or from whom it is received. If you see other medical personnel or use hospitals they may have other practices or policies about how your protected information is handled.
This notice will tell you about the ways that Beckett Ridge Family Medicine may use and disclose medical information about you. It will tell you about your rights and some requirements that we have regarding the use and disclosure of this information. We are required by law to provide you with this notice of our policies regarding your individually identifiable health information.
You DO NOT have to agree with the practices and may request limitations on the use and disclosure of your medical information.
We are required by law to make sure that any medical information that identifies you is kept private, to provide you with this notice about our privacy practices, and to abide by the terms of the agreement that is currently in effect.
There are a number of situations where we may use or disclose to other persons or entities your confidential medical information. Your confidential medical information is defined under federal law as “protected health information” (“PHI”). When Beckett Ridge Family Medicine retains your confidential medical information on its computer system, it is called “electronic protected health information” (“ePHI”). This Notice applies to all PHI and ePHI related to your care that Beckett Ridge Family Medicine has created or received. It also applies to any personal or general information Beckett Ridge Family Medicine receives from patients, including information contained on driver’s licenses. Certain uses and disclosures will require you to sign an Acknowledgement that you received our Notice of Privacy Practices, including treatment, payment and health care procedures. Any use or disclosure of your protected health information required for anything other than treatment, payment or health care procedures requires you to sign an Authorization. Certain disclosures required by law or under emergency circumstances may be made without your Acknowledgement or Authorization. Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure. We will attempt in good faith to obtain your signed Acknowledgement that you received this Notice to use and disclose your confidential medical information.
This section will tell you what ways your medical information will be used. There will be other ways in which your information is used and these examples are not meant to restrict how your information is used and not all information will be used for every purpose.
For Treatment: This is generally the reason you made your appointment with this office. We will use information that we gather to provide you with medical treatment and services. We will gather information regarding the nature of the visit when you call to make your appointment then ask for more information as you are preparing to see our Doctors, or Nurse Practitioners. The provider will gather more information during your encounter and may discuss this with a staff member to determine the correct course of treatment for you. For example, if you call with a laceration the operator may ask information regarding the severity and location of the injury. The office staff may ask about your immunization status or other illnesses that can affect your ability to heal or put you at risk for infection. You may have an x-ray to determine if there is any foreign material in the wound. The provider will ask about how the injury occurred and other information about the injury to determine if there may be other damage not immediately visible. If this injury occurred at work we will share information with your workers compensation insurance company.
For Payment: We may use and disclose medical information about you so that we can receive payment for treatment and services we provide to you. If you ask us to bill your insurance for services we will need to identify you and the services provided to do that. We may need to give your health plan information about you and your medical status to receive preauthorization for services planned.
For Health Care Operations: We may use and disclose information about you for practice operations. The use of this information helps us remain efficient and provide quality care. Information regarding your illnesses may be used to assure that our patients are receiving up to date care in line with guidelines from health plans or national organizations. Information may also be used to evaluate our staff’s performance.
Appointment Reminders: We may use and disclose information to remind you about upcoming appointments for treatment or services at our office.
Treatment Alternatives: We may use and disclose information to tell you about alternative treatments available for you.
Individuals Involved in Your Care: We may release information about you to family members involved in caring for you or, in the event of a disaster, relief agencies providing services to you.
As Required by Law: We will disclose information about you when required to do so by federal, state, or local law.
To Avoid Serious Threat to Health and Safety: We may use and disclose information about you when necessary to prevent a serious threat to you or to the health and safety of the public.
Worker’s Compensation: We may release information about you for worker’s compensation or similar programs that provide benefits for work related injuries or illnesses.
Public Health Risks: We may disclose information about you for public health activities.
To maintain vital records such as birth or death.
To prevent or control disease, injury, or disability
To report child abuse or neglect.
To report reactions to medication or problems with products.
To notify people of recalls of products they may be using.
To notify patients who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence as provided for by Pennsylvania law.
Health Oversight Activities: We may disclose information about you to a health oversight agency for activities such as audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor programs and compliance with civil rights laws.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute we may disclose information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other legal process.
Law Enforcement: Under certain circumstances we may release information about you if asked to do so by a law enforcement official:
To identify suspects, witnesses or missing persons
About the victim of a crime
About deaths we believe may be the result of criminal activity
About criminal conduct at any of our offices
In an emergency to report a crime, crime victim or the individual who committed a crime
In response to a warrant, summons, court order, subpoena, or similar legal process
Coroners, Medical Examiners, and Funeral Directors: We may release information to these individuals, for example, to help with identification, determination of death causes, or to help them perform the duties of their jobs.
National Security and Intelligence Activities: If necessary, we will release information about you to federal officials for intelligence, counter intelligence, or national security activities authorized by law.
Protective Services for the President and Others: We will release information about you to authorized federal officials so that they may provide protection to the President of the United States, other authorized individuals, or foreign heads of state. We also may provide information about you to assist in carrying out an investigation.
Inmates: If you are an inmate of a correctional facility we will release information about you to the correctional institution or law enforcement official.
Worker’s Compensation: Our practice may release your individually identifiable health information for worker’s compensation or other similar programs.
Right to Inspect and Copy: You have the right to review and copy the information that we have used to make medical decisions about your care. This means that we will give you access to medical and billing information, but does not necessarily include access to any psychotherapy notes that we may possess. We reserve the right to have a staff member with you during your review. To inspect and/or obtain a copy of information in our records you must submit your request in writing to the manager of the office in which your records are maintained 30 (thirty) days in advance. If you request a copy of the record, we will charge you a fee for the costs of copying, mailing and other supplies involved in the request.
In certain circumstances we may deny your request to inspect and copy information from your records. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Beckett Ridge Family Medicine will review the denial. This will not be the individual who initially denied your request. Beckett Ridge Family Medicine will abide by the decision of the reviewer.
Right to Amend: You may ask to add an amendment to the information we maintain about you if you feel that the record is incorrect or incomplete. To request an amendment, your request must be submitted in writing to the manager of the office in which your records are maintained. You must include a reason that supports your request. The request will be reviewed and a decision made within 30-days and you will be notified of the decision.
We may deny your request for an amendment if it is not in writing or does not include reason that supports the request. We may also deny any request for amendment of your PHI or ePHI if the information was not created by us (unless the originator of the information is no longer available to act on your request); is not part of the designated record set maintained by us; is not part of the information to which you have a right of access; or is already accurate and complete, as determined by us. If we deny your request for an amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.
Right to Accounting of Disclosures: You have the right to request a list of the disclosures of your medical record that we have made. An “accounting of disclosures” is a list of non-routine disclosures our practice has made of your individually identifiable health information for non-treatment or operations purposes. The routine use and disclosures permitted by the Health Information Portability and Accountability Act is not required to be documented. For example, a provider discussing your case with a nurse or the billing office submitting a claim in not required to be documented. This list will include only disclosures that we have made in writing, and specifically will not include any disclosures made in conversations regarding your treatment, payment, or other health care operations.
To request this accounting you must submit your request, in writing, to the manager of the office in which your records are maintained. Your request must state a time period for accounting that may not be longer than six years, and may not include dates before Apri1 14, 2003. The first list that you request within a 12-month period will be free. There may be a charge for any other requested lists within 12 months.
Right to Request Restrictions: You have the right to request restrictions on the information that we disclose about you for treatment, payment or health care procedures. You also have the right to request a limit on the medical information we disclose about you to someone involved in your care or the payment for your care. For example, you could request that we not use or disclose information regarding a treatment or surgery that you had.
To request restrictions on use of your information, you must make your request in writing to the manager of the office where you are being treated. In your request you must tell us: A) What information you want to limit; B) Whether you want to limit our use, disclosure, or both; and C) To whom you want the limitations to apply, for example disclosures to your spouse or children. We reserve the right to review the request for up to 30 (thirty) days before making a decision. We may utilize one extension of not more than 30 (thirty) days for the decision process.
We are not required to agree to your request. If we do agree however we will comply with your request unless the information is required to treat you in an emergency.
Your Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the manager of the office where you are being treated. You are not required to tell us the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you want to be contacted.
Rights Regarding Out-of-pocket Payment: You may also request a restriction on disclosure of protected health information to a health plan for purpose of payment or healthcare operations if you paid for the services out of your own pocket, in full. This does not apply to services that are covered by insurance. You are required to pay cash, in full, for the services before the restriction applies.
Right to Request Electronic Protected Health Information (ePHI): With respect to ePHI, we agree to give you your ePHI in the form and format requested by you, if it is readily producible in that form or format. If it is not readily producible in the form or format requested, we will give you a readable hard copy form. Any directive given to us by you to transmit ePHI must be done in writing by you, signed and clearly identify the designated person and location to send the ePHI. We will provide you access to your PHI or ePHI within thirty (30) days from the date of request.
Right to Request a Paper Copy of this Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have reviewed a copy of this notice electronically you are entitled to a paper copy. To obtain a paper copy of this notice make your request at the front desk of any office or at our billing office and it will be provided to you free of charge.
Right to Breach Notification: You have the right to receive notification from us if any breach of your unsecured protected health information occurs.
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information that we may gather in the future. We will post a copy of this notice in our office. The notice will contain an effective date on the first page.
If you believe that your privacy rights have been violated, you may file a complaint with this practice or with Beckett Ridge Family Medicine. To file a complaint with Beckett Ridge Family Medicine, contact: Beckett Ridge Family Medicine, 4870 Wunnenberg Way, West Chester, Ohio 45069. All complaints must be submitted in writing. You will not be penalized for filing a complaint. This Notice of Privacy Practices shall not be construed as a contract or legally binding agreement. Any non-compliance with any provision of this Notice shall not be construed as a breach of contract, breach of confidentiality, invasion of privacy, misappropriation of name or likeness, violation of any consumer protection law, negligence or violation of any state law. By signing the Acknowledgment of Receipt of this Notice, you agree that the sole legal recourse for our non-compliance with this Notice is to file a written complaint to the Secretary of the U.S. Department of Health and Human Services, and that no complaint or cause of action may be filed in any federal or state court for breach of contract, breach of confidentiality, invasion of privacy, misappropriation of name or likeness, violation of any consumer protection law, negligence or violation of any state law, or under any tort theory.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us with permission to use or disclose information about you, you may revoke that permission, in writing, at any time. You understand that we are unable to “take back” any disclosures that we have already made with your permission and that we are required to keep any records of the care that we provided to you.
Effective Date: April 14, 2003
