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Privacy Notice

Effective Date:  April 8, 2003

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.

This Notice describes how we may use and disclose your protected health information for purposes of treatment, payment and health care operations, and for other purposes that are permitted or required by law.

We are required by law to:

(1) Maintain the privacy of your protected health information

(2)  Provide you with this Notice

(3) Make good faith efforts to obtain your written acknowledgement that you received this notice

(4) Abide by the terms of this Notice; and

(5) Additionally, we reserve the right to change this Notice.  We reserve the right to  make any new Notice that will be adopted effective for all protected health information we maintain. Any new Notice adopted will be presented at your next appointment following the revision or through U.S. Mail.

Protected health information (“PHI”) is defined as demographic and individually identifiable health information about you (individually identifiable health information) that will or may identify you and relates to your past, present or future physical, mental health or condition that involves providing health care services or health care payment.

HOW IS HEALTH CARE OPERATIONS DEFINED?

Health care operations include conducting quality assessment and improvement activities, reviewing the competence or qualifications and accrediting/licensing of health care professionals and plans, fundraising on behalf of The Campbell Foundation, a trust that is authorized under § 501(C)(3) evaluating health care professionals health plans performance, training future health care professionals, insurance activities relating to the renewal of a contract for insurance, conducting or arranging for medical review and auditing services, compiling and analyzing information in anticipation of or for use in civil or criminal legal proceedings, general administrative and business functions necessary for the covered entity to remain a viable business.

WHY DO YOU SIGN AN AUTHORIZATION FORM?

In order to release your protected health information for any reason other than treatment, payment and health care operations, you must sign an authorization that clearly explains how your information will be used. Additionally, information about the following conditions require an authorization even though release of information is related to treatment, payment or health care operations.

Alcoholism/drug abuse treatment – Federal Confidentiality 42 CFR Part 2

Psychotherapy Notes

You may change your mind and revoke your authorization, except in as much as we have relied on the authorization until that point or if the authorization was obtained as a condition of obtaining insurance coverage.  All requests to revoke an authorization should be in writing.

HOW ARE PSYCHOTHERAPY NOTES DEFINED?

Psychotherapy notes are notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record.  Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

HOW DOES FEDERAL REGULATION 42 C.F.R. PART 2 APPLY TO MEDICAL RECORDS CONTAINING ALCOHOLISM/DRUG ABUSE TREATMENT NOTES?

These regulations cover any information (including information on referral and intake) about alcohol and drug abuse patients obtained by a program (as the terms “patient” and “program” are defined in § 2.11) if the program is federally assisted in any manner described in § 2.12(b).  Coverage includes, but is not limited to, those treatment or rehabilitation programs, employee assistance programs, programs within general hospitals, school-based programs, and private practitioners who hold themselves out as providing, and provide alcohol and drug abuse diagnosis, treatment, or referral for treatment.  However, these regulations would not apply, for example, to emergency room personnel who refer a patient to the intensive care unit for an apparent overdose, unless the primary function of such personnel is the provision of alcohol or drug abuse diagnosis, treatment or referral and they are identified as providing such services or the emergency room has promoted itself to the community as a provider of such services.

HOW IS YOUR MEDICAL INFORMATION USED?

Campbell Clinic uses medical records as a basis for recording individually identifiable health information and planning care and treatment and as a tool for routine health care operations such as assessing quality.  Your insurance company may request information that we are required to submit in order to provide and bill for your care, such as procedure and diagnosis information.  Other health care providers or health plans reviewing your records must follow the same confidentiality laws and rules required of Campbell Clinic. Patient records are a valuable tool used by researchers in finding the best possible treatment for diseases and medical conditions.  All researchers must follow the same rules and laws that other health care providers are required to follow to ensure the privacy of your patient information.  Information that may identify you will not be released for research purposes to anyone outside of Campbell Clinic without your written authorization.

SPECIFIC EXAMPLES OF HOW YOUR MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS

Medical information will/may be used to justify needed patient care services, (i.e., lab tests, prescriptions).

We will/may use your medical information to establish a treatment plan.

We may disclose your protected health information to another provider for treatment (e.g., specialist, pharmacy, laboratory).

We will/may submit claims to your insurance company containing medical information.

We will/may contact you to remind you of your appointment by calling you or mailing a postcard.

We may contact you to discuss treatment alternatives or other health related benefits that may be of interest to you as a patient.

Campbell Clinic uses medical records as a basis for recording individually identifiable health information and planning care and treatment and as a tool for routine health care operations such as assessing quality.

We may use certain information (name, address, telephone number, dates of service, age and gender) to contact you in the future to raise money for the Campbell Foundation.  The money raised will be used to advance orthopaedic medicine through its investment in research, physician education and community health initiatives.  If you do not wish to be contacted for our fundraising efforts, you must notify in writing:  Executive Director of Development, Campbell Foundation, 1400 S. Germantown Road, Germantown, TN  38138.

USE OF YOUR AUTHORIZATION

Campbell Clinic will contractually require our business associates to follow the same confidentiality laws and rules required of Campbell Clinic, health care providers or health plans.  We will not allow others outside of Campbell Clinic and Campbell Clinic’ s business associates to have access to your medical information unless we have the appropriate authorization to do so.  Business Associates perform various activities such as billing services, transcription services, etc.  We will provide this Notice and request your acknowledgement of receipt of this Notice and may request your authorization to release information at your first visit.  With your consent, Campbell Clinic will release information as required for treatment, payment and health care operations only, with certain restrictions.  With your authorization, we will release the information that you have approved for release.

WHEN YOUR AUTHORIZATION IS NOT REQUIRED.

Please note that the law requires some information to be disclosed in certain circumstances.  This includes mandatory reports of abuse of children or elderly or disabled persons.  Additionally, this includes uses and disclosures to the public health authority or federal/state entity that is authorized by law to collect or receive such information.  One example of the public health authorities purpose is preventing and controlling disease.  An example of a federal entity is the Food and Drug Administration.  An example of a state entity is the State Department of Health that is authorized to receive a variety of data concerning different health conditions.  Also, subpoenas or court orders may compel the disclosure of confidential health information in the context of a lawsuit or administrative proceeding.  See complete list below:

Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your acknowledgement of receipt by you of your rights under this Notice as soon as reasonably practicable after the delivery of treatment. If your physician or another physician in the practice is required by law to treat you, he or she may still use or disclose your protected health information to treat you.

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your protected health information to researchers 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 protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of federal law.

A summary of your rights:

All of your rights may be exercised by contacting the Privacy Liaison or Privacy Officer of Campbell Clinic.

The Patient Notice, which you are now reviewing, is part of your patient rights.  You have the right to receive and read this Notice.

You have a right to request restrictions regarding how we use and disclose your protected health information regarding treatment, payment, health care operations, however, we are not required to agree to your restrictions.  If we do agree to your requested restriction we will follow your request, unless you are in need of emergency treatment, and the information is needed to provide emergency care.  However, your restriction (if agreed to) will not prevent us from releasing information as required by other state and federal laws.  [see WHEN YOUR AUTHORIZATION IS NOT REQUIRED].  Finally, if we accept your restrictions, we have the right to terminate them by notifying you of such.

You have a right to request that we communicate about your treatment and/or protected health information by alternative means or at alternative locations.  We are required to accept reasonable requests.  We require that you make this request in writing.

You have the right to ask questions and to receive answers.

You do not have to sign an authorization form, however, it may prevent us from completing a task you have requested (such as enrollment in a research study or examining you to create a report for your attorney).

Your refusal to sign an authorization form will not be held against you.

You may change your mind and revoke your authorization, except in as much as we have relied on the authorization until that point or if the authorization was obtained as a condition of obtaining insurance coverage.

You have the right to inspect and copy your protected health information, as permitted by law.

You have the right to request amendments to your protected health information.  We require that all requests for amendments be in writing and provide a reason to support the requested amendment.  An amendment to your medical record will be made in the form of an addendum as is common practice in the medical field.  Additionally, under federal law, we may deny the amendment, please contact the Privacy Liaison or Officer of Campbell Clinic for details and to exercise your rights.

You have the right to an accounting of all entities that obtained information unrelated to treatment, payment or health care operations.

You have the right to an accounting of all entities that obtained information unrelated to treatment, payment or healthcare operations that you do not approve by completing an authorization.

You have a right to this Notice.  Any material revisions to this Notice will be made available to you within 60 days.

You have a right to contact the Privacy Officer of Campbell Clinic at (901) 759-3102, to request additional information or ask questions.

You may complain to the Privacy Officer of Campbell Clinic at (901) 759-3102 and to the Secretary of the Department of Health and Human Services if you feel your privacy rights have been violated.  Campbell Clinic will not retaliate against you for filing a complaint.


Effective April 8, 2003, you will be asked to sign an “Acknowledgment of Receipt” of the above privacy notice.  This signature page will be distributed by the receptionist upon your arrival.  To allow time for completion of this federally required policy along with other paperwork, please arrive 20-30 minutes prior to your appointment time.