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.
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