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| NOTICE
OF PRIVACY PRACTICES
Effective
April 14, 2003 |
This notice describes how protected health
information about you may be used
and disclosed and how you can get access to this information.
Please review it carefully.
Our company is dedicated to maintaining the privacy of
your identifiable health information. In conducting our
business, we will create records regarding you and the
services we provide to you. Th is Notice tells you about
the ways in which Connetquot West (referred to as “we”
or Connetquot West) may collect, use, and disclose your
protected health information and your rights concerning
your protected health information. “Protected health
information” is information about you that can reasonably
be used to serve you and that relates to you, or the payment
for that care. We are required by law to maintain the
confidentiality of health information that identifies
you; as well as by federal and state laws to provide you
with this Notice about your rights and our legal duties
and privacy practices with respect to your protected health
information. We must follow the terms of this Notice while
it is in effect. Some of the uses and disclosures described
in this Notice may be limited in certain cases by applicable
state laws that are more stringent than the federal standards.
If you have questions about this notice, please contact
the Privacy Officer at Connetquot West at 866-588-3888
for further information.
The terms of this notice apply to all records containing
your health information that are created or retained by
our organization. We reserve the right to revise or amend
our notice of privacy practices. Any revision or amendment
to this notice will be effective for all of your records
our practice has created or maintained in the past, and
for any of your records we may create or maintain in the
future. Our organization will post a copy of our current
notice in our office in a prominent location, and you
may request a copy of our most current notice by calling
us.
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HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
We may use and disclose your protected health information
for different purposes. The examples below are provided to
illustrate the types of uses and disclosures we may make without
your authorization for payment, home care operations, and
treatment.
Payment. We use and disclose your protected health
information in order bill and collect payment for the services
and items you may receive from us. For example, we may contact
your health insurer to certify that you are eligible for benefits
and we may provide your insurer with details regarding your
treatment to determine if your insurer will cover, or pay
for, your equipment. We also may use and disclose your health
information to obtain payment from third parties that may
be responsible for such costs, such as family members. Also,
we may use your health information to bill you directly or
services and items.
Home Care Operations. We use and disclose your protected
health information in order to perform our home care activities,
such as providing equipment appropriate to your needs, or
administrative activities, including data management or quality
assessment activities.
Treatment. We may use and disclose your protected
health information to coordinate services with other health
care providers involved in your care. For example, we may
perform an oximetry test to evaluate the appropriateness of
oxygen equipment; collect measurements to identify appropriate
seating and mobility system(s). We may obtain and disclose
information on Arterial Blood Gases, oxygen saturation results,
CPT diagnosis codes, diagnosis and prognosis, functional limitations,
pre-existing health conditions, hospitalizations, prior use
of equipment, and information specific to qualifying the patient
as dictated by CMN / detailed written order forms.
Appointment Reminders. We may use and disclose your
health information to contact you and remind you of visits
/ deliveries.
Health-related Benefits and Services. We may use
and disclose your health information to inform you of health-related
benefits or services that may be of interest to you.
Release of information to Family/afriends. We may
release your health information to a friend or family member
that helps you to pay for your health care, or who assists
in taking care of you.
Disclosures Required by Law. We will use and disclose
your health information when we are required to do so by federal,
state or local law.
OTHER PERMITTED OR REQUIRED DISCLOSURES
As Required by Law. We must disclose protected
health information about you when required to do so by law.
Public Health Activities. We may disclose protected
health information to public health agencies for reasons such
as preventing or controlling disease, injury, or disability.
Victims of Abuse, Neglect, or Domestic Violence.
We may disclose protected health information to government
agencies about abuse, neglect, or domestic violence.
Health Oversight Activities. We may disclose protected
health information to government oversight agencies. 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.
Judicial and Administrative Proceedings. We may disclose
protected health information in response to a court or administrative
order. We may also disclose protected health information about
you in certain cases in response to a subpoena, discovery
request, or other lawful process.
Law Enforcement. We may disclose protected health
information under limited circumstances to a law enforcement
official in response to a warrant or similar process; to identify
or locate a suspect; or to provide information about the victim
of a crime.
To Avert a Serious Threat to Health or Safety.
We may disclose protected health information about you, with
some limitations, when necessary to prevent a serious threat
to your health and safety or the health and safety of the
public or another person.
Special Government Functions. We may disclose information
as required by military authorities or to authorized federal
officials for national security and intelligence activities.
Workers Compensation. We may disclose protected health
information to the extent necessary to comply with state law
for workers’ compensation programs.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have certain rights regarding protected health
information that the Plan maintains about you.
Right To Access Your Protected Health Information. You
have the right to review or obtain copies of your protected
health information records, with some limited exceptions.
Usually the records include referral information, delivery
forms, billing, claims payment, and medical management records.
Your request to review and/or obtain a copy of your protected
health information records must be made in writing. We may
charge a fee for the costs of producing, copying, and mailing
your requested information, but we will tell you the cost
in advance.
Right To Amend Your Protected Health Information.
If you feel that protected health information maintained by
us is incorrect or incomplete, you may request that we amend
the information. Your request must be made in writing and
must include the reason you are seeking a change. We may deny
your request if, for example, you ask us to amend information
that was not created by us, or you ask to amend a record that
is already accurate and complete. If we deny your request
to amend, we will notify you in writing. You then have the
right to submit to us a written statement of disagreement
with our decision and we have the right to rebut that statement.
Right to an Accounting of Disclosures. You have the
right to request an accounting of disclosures we have made
of your protected health information. The list will not include
our disclosures related to your treatment, our payment or
health care operations, or disclosures made to you or with
your authorization. The list may also exclude certain other
disclosures, such as for national security purposes. Your
request for an accounting of disclosures must be made in writing
and must state a time period for which you want an accounting.
This time period may not be longer than six years and may
not include dates before April 14, 2003. Your request should
indicate in what form you want the list (for example, on paper
or electronically). The first accounting that you request
within a 12-month period will be free. For additional lists
within the same time period, we may charge for providing the
accounting, but we will tell you the cost in advance.
Right To Request Restrictions on the Use and Disclosure of
Your Protected Health Information. You have the right
to request that we restrict or limit how we use or disclose
your protected health information for services, payment, or
health care operations. We may not agree to your request.
If we do agree, we will comply with your request unless the
information is needed for an emergency. Your request for a
restriction must be made in writing. In your request, you
must tell us (1) what information you want to limit; (2) whether
you want to limit how we use or disclose your information,
or both; and (3) to whom you want the restrictions to apply.
Right To Receive Confidential Communications. You
have the right to request that we use a certain method to
communicate with you or that we send information to a certain
location. For example, you may ask that we contact you at
work rather than at home. Your request to receive confidential
communications must be made in writing.. We will accommodate
all reasonable requests. Your request must specify how or
where you wish to be contacted.
Right to a Paper Copy of This Notice. You have a
right at any time to request a paper copy of this Notice.
You may ask us to give you a copy of this notice at any time.
Contact Information for Exercising Your Rights. You
may exercise any of the rights described above by contacting
our privacy Office.
Complaints. If you believe that your privacy rights
have been violated, you may file a complaint with us and/or
with the Secretary of the Department of Health and Human Services.
All complaints must be submitted in writing. You will not
be penalized for filing a complaint. |
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