MEDICAL RADIOLOGISTS, INC.
NOTICE OF PRIVACY PRACTICES
Effective
Date:
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.
WHO WILL FOLLOW THIS
NOTICE?
This Notice describes the
practices of
OUR PLEDGE REGARDING YOUR
PROTECTED HEALTH INFORMATION
MRI understands that medical information about you and your health is personal. We are committed to protecting medical information about you. We maintain our records and conduct our treatment environment with a goal of providing the highest level of protection for your medical information, while still providing you with the highest level of medical care. This Notice applies to all of the records of your medical care which are received or created by MRI.
Your other medical treatment providers (e.g., doctors, hospitals, home health agencies, etc.) may have different policies or notices regarding the use and disclosure of your medical information.
This Notice will tell you about the ways in which MRI may use and disclose medical information about you. Your medical information, also referred to as "protected health information," is that information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health information and related health care services. In this Notice, we also describe your rights and certain obligations MRI has regarding the use and disclosure of protected health information. We are required by law to:
- make sure that medical and other information that identifies you (protected health information) is kept private;
- give you this Notice of our legal duties and privacy practices with respect to protected health information about you; and
- follow the terms of the Notice that is currently in effect.
USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH
CARE OPERATIONS
By using the services of MRI, you are giving consent for MRI to use your protected health information for certain activities, including treatment, payment and other health care operations.
First of all, we may use and disclose protected health information about you so that MRI and its medical professionals can assist your other medical providers in treating you. For example, we will use your protected health information to perform and read your tests. We may also use and disclose protected health information about you so that we may be paid for the services we provide you. For example, we may use your protected health information to bill you or your insurance company for services we provide you. We may also use and disclose protected health information about you for MRI health care operations, in other words, those other tasks that we need to perform to make sure that you are provided the highest quality of medical care. For example, we may use your protected health information to review our internal processes and procedures or to make sure our physicians are doing their jobs properly.
The following uses of your protected health information may be made without any additional authorization from you. (Not every use or disclosure is listed, but be assured that all uses and disclosures made by MRI are only those which are permitted under the law):
USES AND DISCLOSURES TO OTHERS INVOLVED IN YOUR HEALTH
CARE
We may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person’s involvement in your medical care. If you are unable to agree or object to this disclosure, we may disclose such information as necessary if we determine that it is in your best interests based on our professional judgment. We may also use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
USES AND DISCLOSURES IN EMERGENCY SITUATIONS
We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will attempt to obtain your acknowledgment of this Notice as soon as reasonably practicable after the delivery of treatment.
USES AND DISCLOSURES FOR
HEALTH-RELATED BENEFITS OR SERVICES
From time to time, MRI may use and disclose protected health information to tell you about certain health-related benefits or services that may be of interest to you. [IF NOT GOING TO DO THIS, DELETE.]
USES AND DISCLOSURES REQUIRED BY LAW
We will use or disclose protected health information about you when required to do so by federal, state, or local 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, if the law requires us to do so, of any such uses or disclosures. 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 law.
USES AND DISCLOSURES FOR PUBLIC HEALTH ACTIVITIES
We may disclose your protected health information for public health activities and disclosure for such purposes will be to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for purposes such as controlling disease, injury or disability. Disclosures to public health authorities may include disclosure to a foreign authority that is working with the public health authority.
USES AND DISCLOSURES RELATED TO 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.
DISCLOSURES FOR HEALTH
OVERSIGHT ACTIVITIES
We may disclose protected health information to a health oversight agency for activities authorized by law. These activities include, for example, audits, investigations, and inspections. These activities are necessary for the government to monitor the health care system, the delivery of health care, government benefit programs, other government regulatory programs and civil rights laws.
DISCLOSURES OF ABUSE OR NEGLECT
We may disclose your protected
health information to a public health authority 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 a governmental
entity or agency authorized to receive such information. In such cases, the disclosure will only be made
in accordance with
DISCLOSURES TO THE FOOD AND DRUG ADMINISTRATION
We may disclose your protected health information to a person or company required by the Food and Drug Administration (FDA) to report adverse events, product defects or other problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements; or to conduct post-market surveillance, as required.
DISCLOSURES FOR LAWSUITS AND
DISPUTES
If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court order or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
DISCLOSURES TO LAW ENFORCEMENT
We may release protected health
information if asked to do so by a law enforcement official, in response to a
court order, subpoena, warrant, summons, or similar process. Other related disclosures may include
disclosures relating to individuals who are Armed Forces personnel, to national
security and intelligence agencies, as well as disclosures to authorized
federal officials for the protection of the President of the
DISCLOSURES TO CORONERS, FUNERAL DIRECTORS, AND ORGAN DONATION
We may disclose protected health information about you to a coroner or medical examiner for identification purposes, determining cause of death, or for the coroner or medical examiner to perform other duties required by law. We may also disclose protected health information about you to a funeral director in order to permit the funeral director to carry out legal duties, and may do so if death is reasonably anticipated. Your protected health information may also be disclosed for certain organ donations to which you may have agreed.
DISCLOSURES FOR RESEARCH
We may disclose your protected health information to researchers when their research has been approved and protocols have been established to ensure the privacy of your information. We may also disclose a limited set of your information, as allowed under the law, for research purposes.
DISCLOSURES RELATED TO CRIMINAL ACTIVITY
We may disclose your protected
health information, consistent with federal and
DISCLOSURES FOR WORKERS’ COMPENSATION
We may release protected health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
YOUR
RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.
Right to Inspect and Copy. You have the right to inspect and copy protected health information that may be used to make decisions about your medical care. Usually this right includes both medical and billing records. You must submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. Your request to inspect and copy your information may only be denied in very limited circumstances and you have a right to request that any such denial be reviewed.
Right to
Request Restrictions. You
have the right to request that we restrict the use and disclosure of your
protected health information for treatment, payment and health care
operations. We are not required to
agree to your request. If we do
agree, we will comply with your request unless the information is needed to
provide you emergency treatment. To
request restrictions, you must make your request in writing to:
Right to
Confidential Communications.
You also have the right to request to receive private health
information communications (such as test results) by alternative means or at
alternative locations. For example, you
can ask that we only contact you at work or by mail. To request confidential communications, you
must make your request in writing to:
Right to
Amend. If you feel
that the protected health information we have about you is incorrect or
incomplete, you have the right to request that your protected health
information be amended. Only the health
care entity (e.g., doctor, hospital, clinic, etc.) that created your protected
health information is responsible for amending it. For more information regarding the procedures
for submitting such a request, contact
Right to an
Accounting of Disclosures.
You have a right to an accounting of disclosures of your protected
health information, for purposes other than treatment, payment or health care
operations by MRI or any of the people or companies who perform treatment,
payment or health care operations on our behalf. To request this list of disclosures we made
of protected health information about you, you must submit a request in writing
to
Right to a Paper Copy of this Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this notice at any time.
- You may obtain a copy of this Notice at our website: medicalradiologists.com
- To obtain a paper copy of this Notice, contact our Privacy Office: (937) 296-0253.
To learn more about these
procedures, or to make any of these requests, you should contact
CHANGES TO THIS NOTICE
MRI reserves the right to change this notice. We reserve the right to make the revised or changed Notice effective for protected health information we already have about you, as well as any information we create or receive in the future. We will post a copy of the current Notice on MRI’s website. The Notice will contain, in the top right-hand corner, the effective date.
COMPLAINTS
If you believe your privacy
rights have been violated and/or that MRI has not followed this policy, you may
file a complaint with MRI or with the Department of Health and Human
Services. To file a complaint with MRI
or for more information, contact:
OTHER USES OF PROTECTED
HEALTH INFORMATION
Other uses and disclosures of your protected health information not covered by this notice or the laws that apply to MRI will be made only with your written permission (“authorization”). If you provide us permission to use or disclose protected health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the medical treatment or other services that we have provided to you.
QUESTIONS?
If you have any questions
regarding this notice, please contact
ACKNOWLEDGMENT FORM
Our Notice of Privacy Practices (Notice) provides information about how we may use and disclose protected health information about you. You have the right to receive and review our Notice before signing this acknowledgment. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy.
By signing this form, you acknowledge that you have received our Notice now in effect, which details the ways in which MRI is permitted to use and disclose protected health information about you. You also acknowledge that a copy of our Notice has been provided to you to take home with you, that you understand how our Notice applies to you, and that your questions regarding the contents of our Notice have been answered.
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Date Name
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For Office Use
Only
I, in good faith, attempted to obtain the patient's signature in acknowledgement of receipt of CFC's Notice of Privacy Practices, but was unable to do so, as documented below:
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