Clovis Urgent Care
NOTICE OF PRIVACY PRACTICES
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 you have any questions about this notice, please contact our Privacy Officer at 555-555-5555
Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of any health information that identifies you (your “Health Information”). We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your Health Information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect February 23, 2016, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. Any change in this notice could apply to Health Information we already have about you, as well as any information we receive in the future. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available.
You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.
Uses and Disclosures of Health Information
This notice describes the ways we may use and disclose your Health Information. Except for the purposes described in this notice, we will use and disclose your Health Information only with your written permission.
Treatment: We may use or disclose your Health Information to physicians, nurses, or other health care providers in order to provide treatment for you. For example, we may disclose your Health Information to a pharmacy to fill a prescription or to a laboratory to order a blood test. We may also disclose your Health Information to other physicians who may be treating you or who have consulted us about your medical care.
Payment: We may use and disclose your Health Information so that we may bill and receive payment from you, your insurance company, or a third party for the services we provide to you. For example, we may disclose your Health Information to your insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan.
Health Care Operations: We may use and disclose your Health Information in connection with our health care operations. These uses and disclosures are necessary to make sure that all our patients receive quality care and to operate and manage our offices. For example, we may use and disclose your Health Information to evaluate the performance of our staff providing your care. We may combine the Health Information about many patients to determine if additional services should be added or perhaps are no longer needed. We may also disclose your Health Information to other health care providers, students and personnel for learning and quality improvement purposes. We may remove information that identifies you so that others may study your health data without knowing who you are. We may also disclose your Health Information to other entities who have a relationship with you for their own health care operations activities.
Contacting You: We may use and disclose your Health Information to contact you about appointments and other matters. We may also use your Health Information to contact you with information about our health-related benefits and services, or about treatment alternatives that may be of interest to you. We may use a third party to assist us in making these types of communications to you.
To Your Family and Friends: Unless you object, we may disclose your Health Information to individuals involved in your medical care or payment for your care, such as a family member or friend or other person to the extent necessary to help with your health care or with payment for your health care. We may also notify your family about your location or general condition or disclose such information to an entity assisting in disaster relief efforts.
If you are not present, or in the event of your incapacity or an emergency, we will disclose your Health Information based on our professional judgment of whether the disclosure would be in your best interest. We will also use our professional judgment to allow an individual to pick up filled prescriptions, medical supplies, x-rays or other similar items on your behalf.
Research: We may use and disclose Health Information for research, or to prepare to perform research, subject to the confidentiality provisions of applicable federal and state law.
As Required by Law: We will disclose your Health Information when required to do so by international, federal, state, or local law.
Special Circumstances: We may use or disclose your Health Information under the following special circumstances:
- For public health and safety activities, such as to prevent or control disease, to report births and deaths, to report child abuse and neglect, or to report reactions to medications or problems with medical products.
- To health oversight agencies for activities authorized by law, such as for audits, investigations or inspections.
- To report abuse, neglect or domestic violence, provided that any such disclosure is authorized or required by law.
- To avert a serious and imminent threat to your health and safety, or the health and safety of the public or another person.
- To organizations that manage organ, tissue and eye donation and transplantation, if you are an organ donor.
- To coroners, medical examiners, and funeral directors.
- To law enforcement officials, either upon the receipt of a lawful request or as authorized or required by law, for such matters as identifying or locating a suspect or missing person, crimes on our premises, or reporting crimes during emergencies, or to report deaths we believe may be the result of criminal conduct.
- In response to court or administrative orders or other lawful processes.
- To military command authorities if you are a member of the armed forces, as required.
- To authorized federal officials for lawful intelligence, counter-intelligence, and national security activities.
- To a correctional institution, if you are an inmate at such institution or under custody of law enforcement.
- For Workers’ Compensation or similar programs as authorized or required by law.
Use and Disclosure of Certain Types of Health Information: Federal and/or State laws may require us to comply with more strict privacy protections, than we have described in this notice, for certain types of sensitive health Information.
Other Uses and Disclosures of Your Health Information
Other uses and disclosures of Health Information not covered by this notice will be made only with your written authorization. For example, most uses and disclosures of Health Information for certain marketing purposes or disclosures that constitute a sale of Health Information require your written authorization. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
Your Rights Regarding Your Health Information
Right to Inspect and Copy: You have the right to look at or get copies of your Health Information, with certain exceptions. You must make a request in writing to obtain access to your Health Information. You may obtain a form to request access by using the contact information listed at the end of this notice. You may also request access by sending us a letter to the address at the end of this notice. If the information requested is in electronic format then you have the right to your Health Information in electronic format, if it is possible for us to do so. If you request copies, we may charge you a reasonable fee for copying and postage if you want the copies mailed to you. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.
We may deny your request to inspect and copy in limited circumstances as allowed by law. If you are denied access to your Health Information, in most cases, you may have the denial reviewed. Another licensed health care professional chosen by us will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to an Accounting of Disclosures: You have the right to receive a list of certain disclosures we have made of your Health Information. The list will not include disclosures made for the purposes of treatment, payment, or health care operations, disclosures made to you or as authorize by you, or other certain disclosures exempted by law. The list will not include disclosures made earlier than six (6) years before the date of your request. You must make a request in writing to request a listing of disclosures. You may obtain a form to request the accounting by using the contact information at the end of this notice. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.
Right to Request Restrictions: You have the right to request that we place certain restrictions on our use or disclosure of your Health Information for treatment, payment, or health care operations purposes. You also have the right to request a restriction on the Health Information we disclose about you to someone involved in your care or the payment for your care, such as a family member or close friend. We are not required to agree to these additional restrictions except in limited circumstances described below, but if we do, we will abide by our agreement (except in an emergency). Any request for additional restrictions must be made to us in writing. You may obtain a form to request additional restrictions by using the contact information listed at the end of this notice.
We are required to agree to a request not to share your Health Information with your health insurer if three conditions are met: (1) the reason we would disclose to the insurer is for payment or health care operations, (2) the disclosure is not required by law, and (3) you pay the entire amount at the time of service due for the health care item or service out of your own pocket or another person has paid us in full for you. This restriction does not apply for use and/or disclosure of your Health Information for treatment purposes.
Right to Request Confidential Communications: You have the right to request that we communicate with you about your Health Information by alternative means or to alternative locations. For example, you might request that we contact you only at work or only by mail. You must make your request to us in writing. You may obtain a form to request alternative communications by using the contact information listed at the end of this notice. We must accommodate your request if it is reasonable, specifies the alternative means or location, and provides satisfactory explanation how payments will be handled under the alternative means or location you request.
Right to Amendment: If you feel that Health Information we have about you is incorrect or incomplete, you may ask us to amend the information. Your request must be in writing, and it must explain why the information should be amended. You may obtain a form to request an amendment by using the contact information listed at the end of this notice. We may deny your request if we did not create the information you want amended, if we believe the information to be accurate and complete, or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be attached to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.
Right to a Paper Copy of This Notice: If you receive this notice on our web site or by email, you are entitled to receive this notice in paper form. Please contact us using the information listed at the end of this notice to obtain this notice in paper form.
Right to be Notified in the Event of a Breach: You have the right to be notified if we or one of our business associates discovers a breach of your unsecured Health Information.
Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.
If you are concerned that we may have violated your privacy rights, you may file a complaint by using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services, Office for Civil Rights. We support your right to the privacy of your Health Information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Privacy Officer: Privacy Officer