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.
“Protected Health Information” (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
360 AZ Doc is required by law to maintain the privacy of your PHI, and provide you with this notice of our legal duties and privacy practices with respect to your protected health information, and your rights to access and control it. We reserve the right to change the terms of this notice and will notify you of such changes. You then have the right to object or withdraw as provided in this notice. If you have any questions or objections to this form, please contact our Privacy and Security Officer.
Privacy and Security Officer contact information
Our Privacy and Security Officer can be contacted by mail at 2375 E. Camelback Rd., Suite 600, Phoenix, Arizona 85016; by phone at (623) 340-1110; or by email at firstname.lastname@example.org
Uses and Disclosures of Protected Health Information
Your PHI may be used and disclosed by your healthcare provider, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use or disclosure required by law.
Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose our PHI, as necessary, to a home health agency that provides care to you. For example, your PHI may be provided to a physician to whom you have been referred to ensure the physician has the necessary information to diagnose or treat you.
Payment: Your PHI will be used, as needed to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your PHI in order to support the business activities of this practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your PHI to medical school students that see our patients. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization.
- To Business Associates who provide us with services necessary to operate and function as a medical practice (for example transcription services). We will only provide the minimum information necessary for the associate(s) to perform their function.
- In compliance with federal, state or local laws.
- To assist in public health activities such as tracking diseases or medical devices.
- To inform authorities to protect victims of abuse or neglect.
- In compliance with Federal or state health oversight activities such as fraud investigations.
- In response to law enforcement officials or to judicial orders, subpoenas or other process orders.
- To give coroners, medical examiners and funeral directors information necessary for them to fulfill their duties.
- To facilitate organ and tissue donation or procurement.
- For research done in compliance with laws governing research.
- To avert a threat to health or safety.
- To assist in specialized government functions such as national security, intelligence and protective services.
- To inform military and veteran authorities if you are an armed forces member (active or reserve).
- To inform correctional institutions if you are an inmate.
- To inform workers’ compensation carriers or your employer if you are injured at work. To recommend treatment alternatives.
- PHI of minors will be disclosed to their parents or legal guardians unless prohibited by law.
- For breach reporting purposes or to notify you in the event of a breach of your unsecured PHI.
- As required by state and federal regulations, to the North Carolina Health Information Exchange Authority (NCHIEA), an electronic network that allows participating medical providers to share your health information with one another to facilitate care with other providers or emergency rooms. Contact Doctors Making Housecalls Privacy and Security Officer by email or in writing to request the form to Opt-Out of NCHIEA.
Other Uses and Disclosures which require authorization.
Unless required by law, disclosure of your PHI in the situations below and any others not described in this notice, will be made only with your consent, written authorization, or the opportunity to object. You may revoke your authorization in writing at any time, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
- Communication with family and/or individuals. Unless you object, disclosure of your PHI may be made to a family member, friend, or other individual whom you have identified and is involved in your care or payment for your care.
- Disaster. We may disclose your PHI to disaster relief organizations and/or to notify family members or friends of your location and condition.
- Psychotherapy Notes. We will not disclose psychotherapy notes without your written authorization other than in circumstances allowed by law.
- Marketing. Disclosures for marketing purposes or the sale of your PHI require your written authorization.
Protected Health Information (PHI) and Your Rights
Following is a statement of your rights, subject to certain limitations, with respect to your protected health information. Requests related to your PHI should be made to our Privacy and Security Officer. You have the right to:
Inspect and copy your PHI contained in “designated record sets”; pursuant to your request (reasonable fees may apply). You may request an electronic copy of your medical records and we will make every effort to provide the records in the format you request. “Designated record sets” contain medical and billing records and other records the practice uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action of proceeding; and PHI that is subject to laws which prohibit access.
Request a restriction of you PHI. You may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want that restriction to apply. Your physician is not required to agree to a restriction. If our physician believes it is in your best interest to permit use and disclosure of your PHI it will not be restricted. You then have the right to use another healthcare professional.
Request to receive alternative communication from us. You have a right to request confidential communications from us by alternative means or at an alternative location.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
Have your physician amend your PHI. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare and provide you with a copy of our rebuttal to your statement.
Receive an accounting of certain disclosures we have made,if any, of your PHI for purposes other than treatment; payment; health care operations; notification and communication with family and/or friends; and those required by law.
Receive a notice of breach, in the event a breach of your unsecured protected health information occurs.
You may complain to us or the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated by us. If you wish to file a complaint with us, please submit it via telephone, email, or in writing to our Privacy and Security Officer. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before February 10, 2020