Medicare Sign Up pack sample

www.pnsystem.com page 10 NOTICE OF PRIVACY PRACTICES (HIPAA) 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. Our Agency is providing this Notice of Privacy Practices because the privacy of your health information is very important to you and to us, and in compliance with federal regulations. By “your health information” we mean the information that we maintain specifically identifies you and your health status. Your Rights: You have the right to: Get a copy of your paper or electronic medical record, Correct your paper or electronic medical record, Request confidenƟal communicaƟon, Ask us to limit the informaƟon we share, Get a list of those with whom we’ve shared your informaƟon, Get a copy of this privacy noƟce, Choose someone to act for you, File a complaint if you believe your privacy rights have been violated Your Choices: You have some choices in the way that we use and share informaƟon as we: Tell family and friends about your condiƟon, Provide disaster relief, Include you in a hospital directory, Provide mental health care, Market our services and sell your informaƟon, Raise funds Our Uses and Disclosures: We may use and share your information as we: Treat you, Run our organization, Bill for your services, Help with public health and safety issues, Do research, Comply with the law Respond to organ and tissue donation requests, Work with a medical examiner or funeral director, Address workers’ compensation, law enforcement, and other government requests, Respond to lawsuits and legal actions. Your Rights: When it comes to your health informaƟon, you have certain rights. This secƟon explains your rights and some of our responsibiliƟes to help you. Get an electronic or paper copy of your medical record: You can ask to see or get an electronic or paper copy of your medical record and other health informaƟon we have about you. Ask us how to do this. We will provide a copy or a summary of your health informaƟon, usually within 4 business days of your request. Free of charge. Ask us to correct your medical record: You can ask us to correct health informaƟon about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in wriƟng within 60 days. Request confidential communications: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. Ask us to limit what we use or share: You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information: You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agr eed to r eceive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you: If you have given someone medical power of attor ney or if someone is your legal guar dian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by contacting us. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/ complaints/. We will not retaliate against you for filing a complaint. Your Choices: For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care, Share information in a disaster relief situation. Include your information in a hospital/Agency directory If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: Marketing purposes, Sale of your information, Most sharing of psychotherapy notes. In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures: How do we typically use or share your health informaƟon? We typically use or share your health information in the following ways. Treat you: We can use your health information and share it with other professionals who are tr ating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. Run our organization: We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. Bill for your services: We can use and shar e your health information to bill and get payment from health plans or other entities. Example: We give informaƟon about you to your health insurance plan so it will pay for your services. How else can we use or share your health informaƟon?: We are allowed or required to share your informaƟon in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many condiƟons in the law before we can share your informaƟon for these purposes. For more informaƟon see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html . sample