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Effective Date of this Notice: April 14,
2003
PEDIATRIC ASSOCIATES OF WELLESLEY, INC.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE
REVIEW THIS NOTICE CAREFULLY.
UNDERSTANDING
YOUR HEALTH RECORD INFORMATION
Each
time you visit a hospital, physician or other healthcare provider, a
record of your visit is made. Typically
this record contains your symptoms, examination and test results,
diagnoses, treatment, and plans for future care or treatment.
This information, often referred to as your health or medical
record, serves as a basis for planning your care and treatment and
as a means of communication among the many healthcare professionals
who contribute to your care. Understanding
what is in your medical record and how your health information is
used helps you to ensure its accuracy, better understand who, what,
when, where, and why others may access your health information, and
make more informed decisions regarding authorizing disclosures to
others.
We,
at Pediatric Associates of Wellesley, pledge to provide you with the
highest quality of care and to build a relationship based on trust.
This trust includes our commitment to respect the privacy and
confidentiality of your health information.
This
Notice of our Privacy Practices is being given to you because
federal law gives you the right to be told ahead of time about:
-
How Pediatric Associates of Wellesley will handle your
medical information;
-
What our legal duties are related to your medical
information;
-
What your rights are with regard to your medical information;
-
Methods for filing complaints about our privacy practices.
1.
HOW WE MAY USE AND
DISCLOSE YOUR PROTECTED HEALTH INFORMATION
When
you need health care, you give information about yourself and your
health to doctors, nurses, and other health care workers and staff.
This information, along with the record of care you receive,
is “protected health information” (“PHI” or “health
information”). This
information may be kept in a paper form and/or in an electronic form
on the computer.
(A)
Pediatric Associates of Wellesley uses and discloses (shares)
health information for many different reasons. For some of these uses and disclosures, we will need
to obtain prior written authorization (permission).
However, Pediatrics Associates of Wellesley may legally use
or disclose your health information for treatment, payment, and
health care operations. We
do not need to receive prior authorization for uses and disclosures
described within the following categories:
For each
category of uses or disclosures we will explain what we mean and try
to give some examples. Not
every use or disclosure in a category will be listed.
However, all of the ways we are permitted to use and disclose
information will fall within one of the categories:
Treatment.
We may use medical information about you to provide you with
medical treatment or services.
We may disclose medical information about you to other
doctors, and health care providers involved in your care.
Example: One of
our providers may refer you to a specialist such as a radiologist or
a surgeon. The
specialist may tell you that you need to be admitted to the hospital
for treatment or surgery. All
of the providers in this example will share medical information
about your. This is to
coordinate care before, during and after you go into the hospital.
Payment.
We may use and disclose your health information in order to
bill and collect payment for the treatment and services provided
you. Example:
A bill may be sent to you or a third party payer.
If you have health insurance, information on or accompanying
the bill may include a portion of your health information that
identifies you, as well as, your diagnosis, procedures and supplies
used for treatment. The
insurance company uses the information to tell if you are eligible
for benefits or if the services you received were medically needed
for payment purposes. We
may also provide your health information to our business associates,
such as a billing company, claims processing companies and others
that process our health care claims.
Health
Care Operations.
We may disclose your health information for activities that
are known as health care operations. These activities use health care information for
the purpose of evaluating our performance and finding better ways to
provide care. We may
use your health information in order to evaluate the quality of
health care services that you received or to evaluate the
performance of the health care professionals who provided health
care services to you. We
may also share your health information with outside parties
(“business associates”) who perform services on behalf of
Pediatric Associates of Wellesley.
These business associates must agree to keep your health
information private. Examples
of activities that make up health care operations include legal
counsel, transcription, storage, auditing and consulting services.
(B)
Other uses of your health information.
Pediatric Associates of Wellesley may also use your health
information to contact you about:
·
scheduled
appointments, registration/insurance updates, pre-procedure
assessments or test results;
·
information
about patient care issues and treatment choices;
·
other
health-related benefits and services that may be of interest to you.
(C)
We may disclose your health information to others without
your consent in certain situations.
Example: If you
need emergency treatment, or if you are unable to communicate with
us (unconscious or in severe pain).
In each of these situations we will try to get your consent.
But, if you are unable to agree or disagree to consent, and
if we think you would consent if you were able to do so, we will
disclose health information without consent.
(D)
Other specific uses and disclosures that DO NOT require your
consent.
(a)
When disclosure of health information is required by federal,
state or local law, administrative or legal proceedings, health
oversight activities, or by law enforcement.
Examples include health information about victims of abuse,
neglect or domestic violence, patients with gunshot or other wounds.
In addition, we disclose health information when ordered in a
legal or administrative proceeding.
(b)
As required by law, we may disclose your health information
to public health or legal authorities charged with preventing or
controlling disease, injury, or disability.
Examples include information about births, deaths, and
various diseases to the government officials in charge of collecting
that data consistent with applicable laws to carry out their duties.
(c)
There are some services provided in our practice through contracts
with business
associates. Examples
include laboratory testing, visiting nurse and home health care
services, phone triage nursing services, and provision of medical
equipment such as nebulizer machines.
When these services are contracted, we may disclose your
health information to our business associates so that they can
perform the job we have requested them to do and bill you or a third
party payer for services rendered.
(d)
Consistent
with applicable law, we may disclose health information to organ
procurement organizations or other entities engaged in procuring,
banking, or transplantation of organs, eye or tissue donation and
transplants.
(e)
In
certain circumstances this practice may provide health information
in order to conduct or participate in medical research.
Your health information will only be used/or disclosed to
researchers when their research has been approved by an
Institutional Review Board (IRB) that has reviewed the research
proposal and established protocols to ensure the privacy of your
health information. An
example of this research would be to assess the outcomes of patients
who had received specific therapy treatments.
(f)
In
order to avoid a serious threat to the health or safety of a person
or the public, we may provide health information to law enforcement
personnel or persons able to prevent or lessen such harm.
(g)
We
may disclose health information of military personnel and veterans
in certain situations. And
we may disclose health information for national security purposes,
such as protecting the President of the United States or conducting
intelligence operations.
(h)
We
may provide health information to the extent authorized by and to
the extent necessary to comply with laws relating to worker’s
compensation or other similar programs.
(i)
We
may use health information to provide appointment reminders or give
you information about, treatment alternatives or other health care
services or benefits we offer.
(E)
Uses and Disclosures Requiring You to have the Opportunity to
Object.
Pediatric Associates of Wellesley, using its best
judgment, may disclose to a family member, friend, or other person
that you indicate, unless you object in whole or in part, health
information relevant to that person’s involvement in your care or
payment related to your care. The
opportunity to get your authorization may be obtained retroactively
in emergency situations.
(F)
All Other Uses and Disclosures Require Your Prior Written
Authorization.
In any other situation not described in Sections 1
(A) – (E), we will ask for your written authorization before
2.
OUR LEGAL DUTIES TO PROTECT YOUR HEALTH INFORMATION
Pediatric Associates of Wellesley is required by
law to:
·
Make
sure that medical information that identifies you is kept private;
·
Provide
you with this notice that explains our privacy practices and how,
when, and why we use and/or disclose (share) your health information
·
Follow
the terms of the Notice currently in effect.
However, we reserve the right to change our privacy policies
and the terms of this notice at any time.
Any changes will apply to the health information we already
have. Before any
important policy change goes into effect, we will change this
Notice, the new Notice will be posted on our web site and in a
clearly visible location within our practice site(s) for public
viewing.
·
You
may request a copy of this Notice at any time from Ms. Dale E.
Barry, our Privacy Officer and you can view a copy of the
notice on our Web site at paofwellesley.com.
3.
YOUR HEALTH INFORMATION RIGHTS
Unless otherwise required by law, your health
record is the physical property of the healthcare practitioner or
facility that compiled it; the information belongs to you.
YOU HAVE THE
RIGHT TO:
(A)
Request
limits on uses and disclosures of your health information for
treatment, payment or health care operations.
We will consider your request but are not legally required to
accept it. If we accept
your request, we will put any limits in writing and abide by them
except in emergency situations.
You may not limit the
uses and disclosures that are legally required or allowed to make.
(B)
Ask
that your health information be communicated to you in a
confidential manner and to be sent to you in different ways.
For example, you may ask for the Practice to contact you by
mail rather than telephone, or only call at your home rather than at
work. Your request must
be in writing and explain the method of contact and location where
you wish to be contacted. We
will try to honor your request so long as we can easily provide it
in the format you request.
(C)
See
and get copies of your health information that we have, but you must
make the request in writing. We
will respond within thirty (30) days from the receipt of your
request. If you ask for
a copy of your records, you will be charged a fee of $5.00.
If your request is denied, we will inform you, in writing,
our reasons for the denial and explain your right to have the denial
reviewed. We may offer to give you a summary or explanation
of the information you requested as long as you agree in advance to
this and to any fees that this might cost.
If you ask for information we do not have, but we know where
it is, we must tell you where to direct your request.
(D)
Receive
an accounting of disclosures (a record of when and to whom, your
health information was shared without your authorization).
You must make this request in writing. You may request as far
back as six years, beginning April 14, 2003.
The listing you get will include the date, name, and address
(if known) of the person or organization receiving it.
It will also include a brief description of the information
given, a brief statement of why the information was shared, or a
copy of the written request for the information.
The list will not include uses or disclosures that you have already
consented to, such as those made for the treatment, payment or
health care operations, directly to you or your family.
The list also will not include uses or disclosures made for
national security purposes, to corrections or law enforcement
personnel, or before April 14, 2003.
We have 60 days to respond to your written request.
If we do not act on your request within 60 days, we will
notify you that we are extending the response time by 30 days.
If we do that we will explain the delay in writing and give
you a new date of when to expect a response.
We will provide this list at no charge, but if you make more
than one request in the same year, we will charge you $15.00 for
each additional request.
(E)
Correct
or update your health information if you believe that there is a
mistake or that a piece of important information is missing.
You must provide the request and your reason for the request
in writing.
We have 60 days to respond to your request.
We may deny your request,
in writing, if the health information is; (i) correct and
complete, (ii) not created by us, (iii) not allowed to be disclosed,
or (iv) not part of our records.
Our written denial will state the reasons for the denial and
explain your rights to file a written statement of disagreement with
the denial. If you do
not file a written statement of disagreement, you have the right to
request that your request and our denial be attached to all future
disclosures of your health information.
4.
HOW TO COMPLAIN ABOUT PRIVACY PRACTICES
If you think that Pediatric Associates of Wellesley
may have violated your privacy rights, or you disagree with a
decision we made about access to your health information, you may
file a complaint with Ms. Dale Barry, our Privacy Officer.
You also may send a written complaint to either:
Office
for Civil Rights – Region I Office –
Office
for Civil Rights
U.S.
Department of Health and Human Services
Government Center
J.F. Kennedy Federal Building – Room 1875
Boston, Massachusetts 02203
OR
to the -
Secretary of the Dept of Health
and Human Services
200 Independence Avenue
S.W. Washington D.C. 20201
OR e-mail
the HHS Secretary – HHS.MAIL@HHS.GOV
Pediatric
Associates of Wellesley will take no retaliatory action against you
if you file a complaint about our privacy
5.
PERSON TO CONTACT FOR INFORMATION
If you have any questions about this Notice or any
complaints about our privacy practices, or would like to know how to
file a complaint with the Secretary of Health and Human Services,
please contact: