Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm LAKE INTERNAL MEDICINE ASSOCIATES NOTICE OF PRIVACY PRACTICES Effective Date: 10/17/2016 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. If yu have any questins abut this Ntice f Privacy Practices ( Ntice ), please cntact: Privacy Officer: Bnnie DeMuth Phne Number: (352) 589-4774 Sectin A: Wh Will Fllw This Ntice? This Ntice describes Lake Internal Medicine s (hereafter referred t as Prvider ) Privacy Practices and that f: Any wrkfrce member authrized t create medical infrmatin referred t as Prtected Health Infrmatin (PHI) which may be used fr purpses such as Treatment, Payment and Healthcare Operatins. These wrkfrce members may include: All emplyees, staff and persnnel. Any member f a vlunteer grup. All students wrking in the practice. Any entity prviding services under the Prvider's directin and cntrl will fllw the terms f this ntice. In additin, these entities, sites and lcatins may share medical infrmatin with each ther fr Treatment, Payment r Healthcare Operatinal purpses described in this Ntice Sectin B: Our Pledge Regarding Medical Infrmatin We understand that medical infrmatin abut yu and yur health is persnal. We are cmmitted t prtecting medical infrmatin abut yu. We create a recrd f the care and services yu receive at the Prvider. We need this recrd t prvide yu with quality care and t cmply with certain legal requirements. This Ntice applies t all f the recrds f yur care generated r maintained by the Prvider, whether made by Prvider persnnel r yur persnal dctr. Page 1 f 10
Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm This Ntice will tell yu abut the ways in which we may use and disclse medical infrmatin abut yu. We als describe yur rights and certain bligatins we have regarding the use and disclsure f medical infrmatin. We are required by law t: Make sure that medical infrmatin that identifies yu is kept private; Make easily available t yu this Ntice f ur legal duties and privacy practices with respect t medical infrmatin abut yu; and Fllw the terms f the Ntice that is currently in effect. Sectin C: Hw We May Use and Disclse Medical Infrmatin Abut Yu The fllwing categries describe different ways that we use and disclse medical infrmatin. Fr each categry f uses r disclsures we will explain what we mean and try t give sme examples. Nt every use r disclsure in a categry will be listed. Hwever, all f the ways we are permitted t use and disclse infrmatin will fall within ne f the categries. Treatment. We may use medical infrmatin abut yu t prvide yu with medical treatment r services. We may disclse medical infrmatin abut yu t dctrs, nurses, technicians, health care students, r ther Prvider persnnel wh are invlved in taking care f yu at the Prvider. Fr example, a dctr treating yu fr a brken leg may need t knw if yu have diabetes because diabetes may slw the healing prcess. The Prvider als may share medical infrmatin abut yu in rder t crdinate the different things yu need, such as referrals, prescriptins, lab wrk and x-rays. We als may disclse medical infrmatin abut yu t peple utside the Prvider wh may be invlved in yur medical care after yu leave the Prvider, such as family members, clergy r thers we use t prvide services that are part f yur care. Payment. We may use and disclse medical infrmatin abut yu s that the treatment and services yu receive at the Prvider may be billed t and payment may be cllected frm yu, an insurance cmpany r a third party. Fr example, we may need t give yur health plan infrmatin abut medical care r services yu received at the Prvider s yur health plan will pay us r reimburse yu fr this care r services. We may als tell yur health plan abut a treatment yu are ging t receive t btain prir apprval r t determine whether yur plan will cver the treatment. Healthcare Operatins. We may use and disclse medical infrmatin abut yu fr Prvider peratins. These uses and disclsures are necessary t run the Prvider and make sure that all f ur patients receive quality care. Fr example, we may use medical Page 2 f 10
Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm infrmatin t review ur treatment and services and t evaluate the perfrmance f ur staff in caring fr yu. We may als cmbine medical infrmatin abut many Prvider patients t decide what additinal services the Prvider shuld ffer, what services are nt needed, and whether certain new treatments are effective. We may als disclse infrmatin t dctrs, nurses, technicians, health care students, and ther Prvider persnnel fr review and learning purpses. We may als cmbine the medical infrmatin we have with medical infrmatin frm ther Prviders t cmpare hw we are ding and see where we can make imprvements in the care and services we ffer. We may remve infrmatin that identifies yu frm this set f medical infrmatin s thers may use it t study health care and health care delivery withut learning a patient's identity. Appintment Reminders. We may use and disclse medical infrmatin t cntact yu as a reminder that yu have an appintment fr treatment r medical care at the Prvider. Treatment Alternatives. We may use and disclse medical infrmatin t tell yu abut r recmmend pssible treatment ptins r alternatives that may be f interest t yu. Health & Related Benefits and Services. We may use and disclse medical infrmatin t tell yu abut health & related benefits r services that may be f interest t yu. Fundraising Activities. If we intend t use yur medical infrmatin fr fund-raising purpses, we will infrm yu f such intent and that yu have a right t pt ut f receiving fundraising cmmunicatins. Accuntable Care Organizatins. The Prvider may be a member f an Accuntable Care Organizatin (ACO). Yur prtected health infrmatin may be used and disclsed t the ACO fr quality measurement assessment and reprting, billing purpses and crdinatin f care. Authrizatins Required. We will nt use yur prtected health infrmatin fr any purpses nt specifically allwed by Federal r State laws r regulatins withut yur written authrizatin; Specifically the fllwing types f uses and disclsures f yur medical infrmatin require an authrizatin; 1) disclsure f psychtherapy ntes; 2) disclsures fr marketing purpses; and 3) disclsures that cnstitute a sale f prtected health infrmatin. Other uses and disclsures nt described in the NPP will nt be made unless an individual prvides an authrizatin and that authrizatins may be revked prspectively at any time by written revcatin. Page 3 f 10
Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm Emergencies. We may use r disclse yur medical infrmatin if yu need emergency treatment r if we are required by law t treat yu but are unable t btain yur cnsent. If this happens, we will try t btain yur cnsent as sn as we reasnably can after we treat yu. Cmmunicatin Barriers. We may use and disclse yur health infrmatin if we are unable t btain yur cnsent because f substantial cmmunicatin barriers, and we believe yu wuld want us t treat yu if we culd cmmunicate with yu. Individuals Invlved in Yur Care r Payment fr Yur Care. We may release medical infrmatin abut yu t a friend r family member wh is invlved in yur medical care and we may als give infrmatin t smene wh helps pay fr yur care, unless yu bject and ask us nt t prvide this infrmatin t specific individuals, in writing. In additin, we may disclse medical infrmatin abut yu t an entity assisting in a disaster relief effrt s that yur family can be ntified abut yur cnditin, status and lcatin. Research. Under certain circumstances, we may use and disclse medical infrmatin abut yu fr research purpses. Fr example, a research prject may invlve cmparing the health and recvery f all patients wh received ne medicatin t thse wh received anther, fr the same cnditin. All research prjects, hwever, are subject t a special apprval prcess. This prcess evaluates a prpsed research prject and its use f medical infrmatin, trying t balance the research needs with patients' need fr privacy f their medical infrmatin. Befre we use r disclse medical infrmatin fr research, the prject will have been apprved thrugh this research apprval prcess, but we may, hwever, disclse medical infrmatin abut yu t peple preparing t cnduct a research prject, fr example, t help them lk fr patients with specific medical needs, s lng as the medical infrmatin they review des nt leave the Prvider. We will almst always generally ask fr yur specific permissin if the researcher will have access t yur name, address r ther infrmatin that reveals wh yu are, r will be invlved in yur care at the Prvider. As Required By Law. We will disclse medical infrmatin abut yu when required t d s by federal, state r lcal law. Business Assciates. We may disclse prtected health infrmatin (PHI) t ur business assciates wh perfrm functins n ur behalf r prvide us with services, if the PHI is necessary fr thse functins r services. If the business assciate cannt perfrm their functin withut access t PHI, access will be granted. All f ur business assciates are bligated, under cntract with us, t prtect the privacy and ensure the security f yur PHI. Page 4 f 10
Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm Data Breach Ntificatin Purpses. We may use r disclse yur PHI t prvide legally required ntices f unauthrized access r disclsure f yur health infrmatin. T Avert a Serius Threat t Health r Safety. We may use and disclse medical infrmatin abut yu when necessary t prevent a serius threat t yur health and safety r the health and safety f the public r anther persn. Any disclsure, hwever, wuld nly be t smene able t help prevent the threat. E-mail Use. E-mail will nly be used fr cmmunicatins with yu fllwing this rganizatin s current plicies and practices and with yur permissin. The use f secured, encrypted e-mail is encuraged. It will be yur respnsibility t prvide prf f secure, encrypted email service. Patient prtal access is secure and preferred. Sectin D: Special Situatins Organ and Tissue Dnatin. If yu are an rgan dnr, we may release medical infrmatin t rganizatins that handle rgan prcurement r rgan, eye r tissue transplantatin r t an rgan dnatin bank, as necessary t facilitate rgan r tissue dnatin and transplantatin. Military and Veterans. If yu are a member f the armed frces, we may release medical infrmatin abut yu as required by military cmmand authrities. We may als release medical infrmatin abut freign military persnnel t the apprpriate freign military authrity. Wrkers' Cmpensatin. We may release medical infrmatin abut yu fr wrkers' cmpensatin r similar prgrams. Public Health Risks. We may disclse medical infrmatin abut yu fr public health activities. These activities generally include the fllwing: t prevent r cntrl disease, injury r disability; t reprt births and deaths; t reprt child abuse r neglect; t reprt reactins t medicatins r prblems with prducts; t ntify peple f recalls f prducts they may be using; t ntify a persn wh may have been expsed t a disease r may be at risk fr cntracting r spreading a disease r cnditin; and Page 5 f 10
Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm t ntify the apprpriate gvernment authrity if we believe a patient has been the victim f abuse, neglect r dmestic vilence. We will nly make this disclsure if yu agree r when required r authrized by law. Health Oversight Activities. We may disclse medical infrmatin t a health versight agency fr activities authrized by law. These versight activities include, fr example, audits, investigatins, inspectins, and licensure. These activities are necessary fr the gvernment t mnitr the health care system, gvernment prgrams, and cmpliance with civil rights laws. Lawsuits and Disputes. If yu are invlved in a lawsuit r a dispute, we may disclse medical infrmatin abut yu in respnse t a curt r administrative rder. We may als disclse medical infrmatin abut yu in respnse t a subpena, discvery request, r ther lawful prcess by smene else invlved in the dispute, but nly if effrts have been made t tell yu abut the request r t btain an rder prtecting the infrmatin requested. Law Enfrcement. We may release medical infrmatin if asked t d s by a law enfrcement fficial: in respnse t a curt rder, subpena, warrant, summns r similar prcess; t identify r lcate a suspect, fugitive, material witness, r missing persn; abut the victim f a crime if, under certain limited circumstances, we are unable t btain the persn's agreement; abut a death we believe may be the result f criminal cnduct; abut criminal cnduct at the Prvider; and in emergency circumstances, t reprt a crime; the lcatin f the crime r victims; r the identity, descriptin r lcatin f the persn wh cmmitted the crime. Crners, Medical Examiners and Funeral Directrs. We may release medical infrmatin t a crner r medical examiner. This may be necessary, fr example, t identify a deceased persn r determine the cause f death. We may als release medical infrmatin abut patients f the Prvider t funeral directrs as necessary t carry ut their duties. Natinal Security and Intelligence Activities. We may release medical infrmatin abut yu t authrized federal fficials fr intelligence, cunterintelligence, and ther natinal security activities authrized by law. Page 6 f 10
Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm Prtective Services fr the President and Others. We may disclse medical infrmatin abut yu t authrized federal fficials s they may prvide prtectin t the President, ther authrized persns r freign heads f state r cnduct special investigatins. Inmates. If yu are an inmate f a crrectinal institutin r under the custdy f a law enfrcement fficial, we may release medical infrmatin abut yu t the crrectinal institutin r law enfrcement fficial. This release wuld be necessary fr the institutin t prvide yu with health care, t prtect yur health and safety r the health and safety f thers, r fr the safety and security f the crrectinal institutin. Sectin E: Yur Rights Regarding Medical Infrmatin Abut Yu Yu have the fllwing rights regarding medical infrmatin we maintain abut yu: Right t Access, Inspect and Cpy. Yu have the right t access, inspect and cpy the medical infrmatin that may be used t make decisins abut yur care, with a few exceptins. Usually, this includes medical and billing recrds, but may nt include psychtherapy ntes. If we maintain yur infrmatin electrnically yu may request a cpy f yur recrds via a mutually agreed upn electrnic frmat. If we fail t agree upn an electrnic frmat fr delivery f electrnic cpies we will prvide yu with a paper cpy fr yur recrds. If yu request a cpy f the infrmatin in either paper r electrnic frmat, we may charge a fee fr the csts f cpying, mailing r ther supplies assciated with yur request. We may deny yur request t inspect and cpy medical infrmatin in certain very limited circumstances. If yu are denied access t medical infrmatin, in sme cases, yu may request that the denial be reviewed. The persn cnducting the review will nt be the persn wh denied yur request. We will cmply with the utcme f the review. Right t Amend. If yu feel that medical infrmatin we have abut yu is incrrect r incmplete, yu may request us t amend the infrmatin. Yu have the right t request an amendment fr as lng as the infrmatin is kept by r fr the Prvider. In additin, yu must prvide a reasn that supprts yur request. We may deny yur request fr an amendment if; it is nt in writing r des nt include a reasn t supprt the request r fr ther reasns. Typical reasns fr denial f an amendment request include if yu ask us t amend infrmatin that: Page 7 f 10
Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm Was nt created by us, unless the persn r entity that created the infrmatin is n lnger available t make the amendment; Is nt part f the medical infrmatin kept by r fr the Prvider; Is nt part f the infrmatin which yu wuld be permitted t inspect and cpy; r Is accurate and cmplete. Right t an Accunting f Disclsures. Yu have the right t request an Accunting f Disclsures. This is a list f the disclsures we made f medical infrmatin abut yu. Yur request must state a time perid which may nt be lnger than six years and may nt include dates befre April 14, 2003. Yur request shuld indicate in what frm yu want the list (fr example, n paper r electrnically, if available). The first list yu request within a 12 mnth perid will be cmplimentary. Fr additinal lists, we may charge yu fr the csts f prviding the list. We will ntify yu f the cst invlved and yu may chse t withdraw r mdify yur request at that time befre any csts are incurred. Right t Request Restrictins. Yu have the right t request a restrictin r limitatin n the medical infrmatin we use r disclse abut yu fr treatment, payment r healthcare peratins. We require that any requests fr use r disclsure f medical infrmatin be made in writing. In sme cases we are nt required t agree t these requests, hwever if we d agree t them we will abide by these restrictins. We will always ntify yu f ur decisins regarding restrictin requests in writing. Yu have the right t request, in writing, a limit n the medical infrmatin we disclse abut yu t smene wh is invlved in yur care r the payment fr yur care, like a family member r friend. Fr example, yu culd ask that we nt use r disclse infrmatin abut a surgery yu had. In yur request, yu must tell us what infrmatin yu want t limit, whether yu want t limit ur use, disclsure r bth, and t whm yu want the limits t apply, fr example, disclsures t yur spuse. Yu als have the right, which we may nt refuse (except as listed belw), t restrict use and disclsure f yur medical infrmatin abut a service r item fr which yu have paid cmpletely ut f pcket, fr payment (i.e. yur insurance cmpany) and peratinal (but nt treatment) purpses, if yu have cmpletely paid yur bill fr this item r service. We are nt required t accept yur request fr this type f restrictin until yu have cmpletely paid yur bill (zer balance) fr this item r service r if the request is cntrary t any law. We are nt required t ntify ther healthcare prviders f these types f restrictins, that is yur respnsibility. Page 8 f 10
Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm Right t Receive Ntice f a Breach. We are required t ntify yu by first class mail r by e-mail (if we ffered and yu have indicated a preference t receive infrmatin by e-mail), f any breaches f Unsecured Prtected Health Infrmatin as sn as pssible, but in any event, n later than 60 days fllwing the discvery f the breach. Unsecured Prtected Health Infrmatin is infrmatin that is nt secured thrugh the use f a technlgy r methdlgy identified by the Secretary f the U.S. Department f Health and Human Services t render the Prtected Health Infrmatin unusable, unreadable, and undecipherable t unauthrized users. The ntice is required t include the fllwing infrmatin: a brief descriptin f the breach, including the date f the breach and the date f its discvery, if knwn; a descriptin f the type f Unsecured Prtected Health Infrmatin invlved in the breach; steps yu shuld take t prtect yurself frm ptential harm resulting frm the breach; a brief descriptin f actins we are taking t investigate the breach, mitigate lsses, and prtect against further breaches; cntact infrmatin, including a tll-free telephne number, e-mail address, Web site r pstal address t permit yu t ask questins r btain additinal infrmatin. In the event the breach invlves 10 r mre patients whse cntact infrmatin is ut f date we will pst a ntice f the breach n the hme page f ur Web site r in a majr print r bradcast media. If the breach invlves mre than 500 patients in the state r jurisdictin, we will send ntices t prminent media utlets. If the breach invlves mre than 500 patients, we are required t immediately ntify the Secretary. We als are required t submit an annual reprt t the Secretary f a breach that invlved less than 500 patients during the year and will maintain a written lg f breaches invlving less than 500 patients. Right t Request Cnfidential Cmmunicatins. Yu have the right t request that we cmmunicate with yu abut medical matters in a certain way r at a certain lcatin. Fr example, yu can ask that we nly cntact yu at wrk r hard cpy via mail. We will nt ask yu the reasn fr yur request. We will accmmdate all reasnable requests. Yur request must specify hw r where yu wish t be cntacted. Right t a Paper Cpy f This Ntice. Yu have the right t a paper cpy f this Ntice. Yu may ask us t give yu a cpy f this Ntice at any time. Even if yu have agreed t receive this Ntice electrnically, yu are still entitled t a paper cpy f this Ntice. Yu may btain a cpy f this Ntice at ur website: www.steventangmd.cm Page 9 f 10
Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm T exercise the abve rights, please cntact the Prvider by telephne at (352) 589-4774 r in writing t btain a cpy f the relevant frm yu will need t cmplete t make yur request. Sectin F: Changes T This Ntice We reserve the right t change this Ntice. We reserve the right t make the revised r changed Ntice effective fr medical infrmatin we already have abut yu as well as any infrmatin we receive in the future. We will pst a cpy f the current Ntice. The Ntice will cntain n the first page, in the tp right hand crner, the effective date. In additin, each time yu register at r are admitted t the Prvider fr treatment r health care services as an inpatient r utpatient, we will ffer yu a cpy f the current Ntice in effect. Sectin G: Cmplaints If yu believe yur privacy rights have been vilated, yu may file a cmplaint with the Prvider r with the Secretary f the Department f Health and Human Services; http://www.hhs.gv/cr/privacy/hipaa/cmplaints/index.html T file a cmplaint with the Prvider, cntact the individual listed n the first page f this Ntice. All cmplaints must be submitted in writing. Yu will nt be penalized fr filing a cmplaint. Sectin H: Other Uses f Medical Infrmatin Other uses and disclsures f medical infrmatin nt cvered by this Ntice r the laws that apply t us will be made nly with yur written permissin. If yu prvide us permissin t use r disclse medical infrmatin abut yu, yu may revke that permissin, in writing, at any time. If yu revke yur permissin, we will n lnger use r disclse medical infrmatin abut yu fr the reasns cvered by yur written authrizatin. Yu understand that we are unable t take back any disclsures we have already made with yur permissin, and that we are required t retain ur recrds f the care that we prvided t yu. Sectin I: Accuntable Care Organizatin (ACO) The Prvider has agreed, as permitted by law, t share yur health infrmatin with an ACO (Primary Care Alliance) fr purpses f treatment, payment r health care peratins, enabling us t better address yur healthcare needs. Page 10 f 10