|
Notice of Privacy Practices for Kirit K. Kothari, M.D. Protected Health Information This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
The Commonwealth of Pennsylvania provides a broad range of services through a wide variety of health and human services programs. If you receive services from a Commonwealth program, the Commonwealth program may use your protected health information and disclose it to other Commonwealth health and human services programs and outside the Commonwealth, to: a. plan and provide your care and treatment b. communicate with health care professionals who care for you c. describe the care you receive
d.
obtain reimbursement from private insurers or other government e. verify that services billed were actually provided f. educate health professionals g. inform public health officials charged with improving healthcare h. administer the Commonwealth's programs which provide public benefits, and/or health or human services i. assess and improve the services provided and the outcomes achieved j. pay for services you receive k. inform you about other public programs and services The Commonwealth and its programs will not use or disclose your protected health information except as described in this notice, or otherwise authorized by law. II. Your Health Information Rights: You have the right to: a. request a restriction on certain uses and disclosures of your protected health information b. obtain a paper copy of this Notice of Information Practices upon request c. inspect and copy your protected health information d. request amendments to your protected health information e. obtain an accounting of disclosures of your protected health information f. request communications of your protected health information by alternative means or at an alternative address g. revoke your consent to use or disclose protected health information to the extent that it has not already been relied upon h. file a complaint to the (Insert name of program) and/or the Secretary of the U.S. Department of Health and Human Service if you believe your privacy rights have been violated. III. The Commonwealth Program Duties: The Commonwealth's health and human services programs each have a duty to: a. maintain the privacy of your protected health information b. provide you with a notice as to our legal duties and privacy practices with respect to protected health information we collect and maintain about you c. abide by the terms of this notice d. notify you if we are unable to agree to a requested restriction e. accommodate reasonable requests you may have to communicate health information by alternative means or at an alternative address f. Provide an accounting of disclosures of your protected health information The Commonwealth or any Commonwealth health and human services program may change its privacy practices and make the new privacy practices effective for all protected health information we maintain. Should our privacy practices change, we will mail a revised notice to the address you have supplied us. IV. For More Information or to Report a Problem: If you have questions and would like additional information, you may contact Marianne Pettis at (570) 992-1234. If you believe your privacy rights have been violated, you can file a complaint with (Privacy Officer) Marianne Pettis or with the Secretary of the United States Department of Health and Human Services. There will be no retaliation for filing a complaint. V. Examples of Disclosures for Treatment, Payment and Health Operations: (Individual programs should amend the following examples of treatment, payment or operations to make it meaningful for the program. The notice must have at least one example of the types of uses and disclosures for treatment, payment and operations.) We will use your health information for treatment. For example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. We will use your health information for payment. For example: A bill may be sent to you or any private or public source of health coverage you have identified. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We will use your health information for regular health operations. For example: Members of a quality assurance team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. VI. Others who may receive your health information Business Associates: there are some services provided in our organization through contracts with business associates. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do. However, we require the business associate to appropriately safeguard your information. Research: We may disclose information to researchers when the information is de-identified or 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 health information. Organ procurement organizations: Consistent with applicable law, we may disclose 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. Funeral Directors: We may disclose health information to funeral directors to carry out their duties, as required by law. Public health: We may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof any health information necessary for your health and the health and safety of other individuals, or for the administration of the institution. Law enforcement: We may disclose health information for law enforcement purposes. |
|||