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.
A federal regulation, known as the “HIPAA Privacy Rule”, requires that we provide detailed notice in writing of our privacy
practices.
As a patient, you have the following rights:
1. The right to inspect and copy your information
2. The right to request corrections to your information
3. The right to request that your information be restricted
4. The right to request confidential communications
5. The right to a report of disclosures of your information; and
6. The right to a paper copy of this notice
Uses and/or disclosures which do not require your written authorization may include:
Treatment: We will use your health information to make decisions about the provision, coordination or management or your
healthcare. It may also be necessary to share your health information with another health care provider whom we need to
consult with respect to your care.
Payment: We may need to use or disclose information in your health record to obtain reimbursement from you, from your
health insurance carrier, or from another insurer for our services rendered to you. This may include determinations of eligibility
or coverage under the appropriate health plan, pre-certification and pre-authorization of services or review of services for the
purpose of reimbursement. This information may also be used for billing, claims management and collection purposes, and
related healthcare data processing through our system.
Operations: Your health records may be used in our business planning and development operations, including improvements
in our methods of operation, and general administrative functions. We may also use the information in our overall compliance
planning, healthcare review activities, and arranging for local and auditing functions.
There are certain other circumstances under which we may use or disclose your health information without first obtaining your
Acknowledgment or Authorization. Those circumstances generally involve public health and oversight activities, law enforcement
activities, judicial and administrative proceedings, and in the event of death. Specifically, we may be required to
report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases or HIV/AIDS
status. We may also be required to report instances of suspected or documented abuse, neglect or domestic violence. We are
required to report to appropriate agencies and law-enforcement officials information that you or another person is in
immediate threat of danger to health or safety as a result of violent activity. We must also provide health information when
ordered by a court of law to do so.
Others Involved in Your Healthcare: Unless you object, 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
health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we
determine that it is in your best interest based on our professional judgment. We may 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
our 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 healthcare.
Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to
obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using
professional judgment, that you intend to consent to use or disclosure under the circumstances. We may use or disclose your
protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon
as reasonably practicable after the delivery of treatment. If we are required by law or as a matter of necessity to treat you, and
we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your
protected health information to treat you.
Except as indicated above, your health information will not be used or disclosed to any other person or entity without your
specific authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to
governmental entities required by law to maintain the confidentiality of the information, information will not be further
disclosed to any other person or entity with respect to information concerning mental health treatment, drug and alcohol
abuse, HIV/AIDS or sexually transmitted diseases that may be contained in your health records. We likewise will not disclose
your health-record information to an employer for purposes of making employment decisions, to a liability insurer or attorney
as a result of injuries sustained in an automobile accident, or to educational authorities, without you written authorization.
You have certain rights regarding your health record information, as follows:
(1) You may request that we restrict the uses and disclosures of your health record information for treatment,
payment and operations, or restrictions involving your care or payment related to that care. We are not
required to agree to the restriction; however, if we agree, we will comply with it, except with regard to
emergencies, disclosure of the information to you, or if we are otherwise required by law to make a full
disclosure without restriction.
(2) You have a right to request receipt of confidential communications of your medical information by an alternative
means or at an alternative location. If you require such an accommodation, you may be charged a fee for the
accommodation and will be required to specify the alternative address or method of contact and how payment
will be handled.
(3) You have the right to inspect, copy and request amendments to your health records. Access to your health
records will not include psychotherapy notes contained in them, or information compiled in anticipation of or for
use in a civil, criminal or administrative action or proceeding to which your access is restricted by law. We will
charge a reasonable fee for providing a copy of your health records, or a summary of those records, at your
request, which includes the cost of copying, postage, and preparation or an explanation or summary of the
information.
(4) All requests for inspection, copying and/or amending information in your health records, and all requests related
to your rights under this Notice, must be made in writing and addressed to the Privacy Officer at our address.
We will respond to your request in a timely fashion.
(5) You have a limited right to receive an accounting of all disclosures we make to other persons or entities of your
health information except for disclosures required for treatment, payment and healthcare operations,
disclosures that require and Authorization, disclosure incidental to another permissible use or disclosure, and
otherwise as allowed by law. We will not charge you for the first accounting in any twelve-month period;
however, we will charge you a reasonable fee for each subsequent request for an accounting within the same
twelve-month period.
(6) If this notice was initially provided to you electronically, you have the right to obtain a paper copy of this notice
and to take one home with you if you wish.
You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights
with respect to confidential information in your health records have been violated. All complaints must be in writing and must
be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of
Health and Human Services if we cannot resolve your concerns. You will not be retaliated against for filing such a complaint.
More information is available about complaints at the government’s website, http://www.hhs.gov/ocr/hipaa.
All questions concerning this Notice or requests made pursuant to it should be addressed to
officemanager@blackstonemedicalservices.com.