THE HAND CENTER OF WESTERN
MASSACHUSETTS
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.
It is very important to The
Hand Center of Western Massachusetts to protect your personal health information
(PHI*). We want you to have a clear
understanding of how we use and safeguard your protected health
information.
We create a record of care and
services you receive at our office or at the recommendation of our office. We need this record to provide you with
quality care, and to comply with certain legal requirements. These Standards for Privacy of
Individually Identifiable Health Information (the “Privacy Regulation”) are
published by the U.S. Department of Health and Human Services (“HHS”) at 45
C.F.R. parts 160 and 164 under the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”). They are interpreted and amended from time
to time, for so long as such regulations are in effect.
This notice of privacy
practices will describe your rights and certain duties we have regarding the use
and disclosure of medical information.
It also describes how we may use your PHI* in order to carry out
treatment, payment, and health care operations. This notice also contains your right to
access and control your PHI*.
We are required to abide by
the terms of this notice. However,
we may modify the terms of this notice at any time, and the new notice will be
effective for all PHI* in our possession at the time of the change, and any
received thereafter. Upon request,
we will provide you with any revised notice or you can review the notice by
accessing our website at http://www.handctr.com/.
We use PHI* about you for
treatment, payment, and health care operation purposes. We do not require authorization to use
your PHI* for these purposes. We
may also use or disclose your PHI* without your authorization for several other
reasons. Subject to certain
requirements, we may give out health information without your authorization for
public health reasons, for auditing purposes, for research studies, and for
emergencies.
Treatment: We may use
PHI* about you to provide you with medical treatment or services. We may disclose PHI* about you to
doctors, nurses, technicians, medical students, or other people who are taking
care of you. We may also share PHI*
about you to your other health care providers to assist them in treating
you.
Payment:
We may use and disclose your PHI*
for payment purposes.
Health Care
Operations: We may use and disclose your PHI* for our health care
operations. This may include
measuring and improving quality, evaluating the performance of employees,
conducting training programs, in getting certificates, accreditations, licenses
and credentials we need to serve you.
Additional Uses and
Disclosures: In addition to using and disclosing your PHI* for
treatment, payment, and health care operations, we may use and disclose PHI* for
the following purposes.
Appointment
reminders: We have the right to
use and disclose your PHI* to contact you and remind you of appointments.
Notification:
We have the right to use and
disclose PHI* to notify or help notify: a family member, your personal
representative, or another person responsible for your care. We will share information about your
*PHI is individually
identifiable information (including demographic information) relating to your
health, to the health care provided to you or payment for health
care.
location, general condition,
or death. If you are present, we
will get your permission if possible before we share, or give you the
opportunity to refuse the permission.
We may also disclose PHI* by
facsimile, email or via cell phone.
In case of emergency, and if
you are not able to give or refuse permission, we will share only the health
information that is directly necessary for your health care, according to our
professional judgment. We will also
use our professional judgment to make decisions in your best interest about
allowing someone to pick up prescriptions, medical supplies, x-rays, office
notes, or any other medical information for you.
Research in Limited
Circumstances: We may provide PHI* for research purposes in limited
circumstances when the research has been approved by a review board that has
reviewed the research proposal and established protocols to ensure the privacy
of the medical information.
Health Related Benefits
and Services: We may use and
disclose PHI* to inform you of health related benefits or services that may be
of interest to you.
Disclosures Required by
Law: We will use and disclose your PHI* when we are required
to do so by federal, state, or local law.
Court Orders and
Judicial and Administrative Proceedings: We may
disclose PHI* in response to a court or administrative order, subpoena,
discovery request or other lawful process, under certain circumstances. Under limited circumstances, such as a
court order, warrant, or grand jury subpoena, we may share your PHI* with law
enforcement officials. We may share
limited information with a law enforcement official concerning the medical
information of a suspect, fugitive, material witness, crime victim, or missing
person. We may share the medical
information of an inmate or other person in lawful custody with a law
enforcement official or a correctional institution under certain
circumstances.
Public Health Risks:
As required by law, we may
disclose your PHI* to public health authorities that are authorized by law to
collect information for the purposes of:
·
maintaining vital
records, such as births and deaths;
·
reporting child abuse or
neglect;
·
preventing or controlling
disease, injury, or disability;
·
notifying a person
regarding potential exposure to a communicable disease;
·
notifying a person
regarding the potential risk for spreading or contracting a disease or
condition;
·
reporting reactions to
drugs or problems with products or devices;
·
notifying individuals of
when a product or device they may be using has been
recalled;
·
notifying the appropriate
government agencies and authorities regarding the potential abuse or neglect of
an adult patient (including domestic violence); and
·
notifying your employer
under limited circumstances related primarily to work place injury or illness or
medical surveillance.
Health
Oversight: We may disclose your PHI* to a health oversight agency
for activities authorized by law, including audits, civil, administrative or
criminal investigations or proceedings; or other activities necessary for the
government to monitor government programs, compliance with civil rights laws and
the health system in general.
Law
Enforcement: We may disclose PHI* if asked by to do so by a law
enforcement official;
·
regarding a crime victim
in certain situations;
·
concerning a death we
believe might have resulted from a criminal conduct;
·
regarding criminal
conduct at our office;
·
to identify and/or locate
a suspect, material witness, fugitive or missing person;
·
in an emergency to report
a crime (such as certain types of wounds).
*PHI is individually
identifiable information (including demographic information) relating to your
health, to the health care provided to you or payment for health
care.
Serious Threats to
Health or Safety:
We may disclose PHI* when necessary to
reduce or prevent a serious threat to your health and safety or the health and
safety of another individual or the public. Under these circumstances, we will only
make disclosures to a personal organization able to help prevent that
threat.
*PHI is individually
identifiable information (including demographic information) relating to your
health, to the health care provided to you or payment for health
care.
Military:
We may disclose your PHI* if you
are a member of the United States or foreign military forces and if required by
the appropriate military command authorities.
National Security:
We may disclose your PHI* to
federal officials for intelligence and national security activities authorized
by the law. We may also disclose to
federal officials in order to protect the president, other officials, or foreign
heads of state, or to conduct investigations.
Inmates:
We may disclose your PHI* to
correctional institutions or law enforcement officials if you are an inmate or
under the custody of a law enforcement official. Disclosures for these purposes would be
necessary: (a) for the institution to provide health care services to you, (b)
for the safety and security of the institution, and/or (c) to protect your
health and safety or the health and safety of other individuals.
Workers’
Compensation: We may disclose your PHI* for workers’ compensation and
similar programs.
Your Rights:
The Right to Inspect and
Copy: You have the right to
inspect (while supervised by an employee of The Hand Center of Western
Massachusetts) and obtain a copy of your PHI* that we maintain and have in our
possession, including medical records and billing records, but not including
psychotherapy notes. If you request
copies, we will charge you a fee for the cost of copying, mailing, labor and
supplies associated with your request.
To inspect and copy your PHI*, you must submit your request in writing.
Original records will not be permitted to leave the premises.
Under certain circumstances,
we may deny your request to inspect and copy your PHI*. If you are denied access to medical
information, you have the right to have that determination reviewed. A licensed health care professional will
review your request and denial. The
person conducting the review will not be the person who denied your
request. The Hand Center of Western
Massachusetts promises to comply with the outcome of the review.
The Right to Amend Your
PHI*: If you feel that any PHI* we have about you is not
correct or is incomplete, you may ask us to amend the information. You have the right to request an
amendment as long as the information is our work product and is kept by The Hand
Center of Western Massachusetts. To
request an amendment, your request must be made in writing. Additionally, you must provide a reason
that supports your request.
The Hand Center of Western
Massachusetts reserves the right to deny your request for an amendment if it is
not in writing or does not include a reason to support the request. In addition, we may deny your request,
if you ask us to amend information that:
·
was not created by The
Hand Center of Western Massachusetts;
·
is not part of the
medical information kept by The Hand Center of Western
Massachusetts;
·
is not part of the
information which you would be permitted to inspect and copy;
or
·
is accurate and complete.
The Right to an
Accounting of Disclosures:
An accounting of disclosures is a list
of the disclosures we have made, if any, of your PHI*.
You have the right to request
an accounting of disclosures. The
right applies to disclosures for purposes other
*PHI is individually
identifiable information (including demographic information) relating to your
health, to the health care provided to you or payment for health
care.
than those made to carry out
treatment, payment, and health care operations as described in this notice. It excludes disclosures made to you, or
those made for notification purposes.
Your request must be made in
writing and state a time period that cannot be longer than seven years and
cannot include any dates before April 14, 2003. We may charge you for the cost of
providing this list. We will notify
you of the cost involved and you may choose to withdraw or modify your request
at any time before any costs are incurred.
The Right to Receive
Communications of PHI* by Alternative Means or at Alternative Locations:
You have the right to request that The Hand Center of
Western Massachusetts communicate with you about your
health related issues in a
particular manner or at a certain location. We will accommodate all reasonable
requests made in writing. Your
request to receive PHI* by an alternative means or at an alternative location
must clearly state that your life could be endangered by the disclosure of all
or part of your PHI*.
The Right to Request
Restrictions: You have the right to request a restriction or
limitation on the PHI* we use or disclose about you for treatment, payment or
health care operations as described in this notice. You also have the right to request a
limit on the medical information we disclose about you to someone who is
involved in your care or the payment of your care (like a family member or
friend), or for notification purposes as described in this notice.
Any request for a restriction
on our use and disclosure of your PHI* must be made in writing. Your request
must describe in a clear and concise manner: (a) the information you wish to be
restricted; (b) whether you are requesting to limit The Hand Center of Western
Massachusetts use, disclosure, or both; and (c) to whom you want the limits to
apply. Please note that certain
restrictions may affect our ability to communicate on your behalf to your
insurance and would therefore leave you responsible for such payments.
The Right to Provide an
Authorization for Other Uses and Disclosures: The Hand
Center of Western Massachusetts will obtain your written authorization for uses
and disclosures that are not identified by this notice or permitted by
applicable law. Any authorization
you provide to us regarding the use and disclosure of your PHI* may be revoked
at any time in writing. After you
revoke your authorization, we will no longer use or disclose your PHI* for the
purposes described in this authorization, except under the following
circumstances:
·
we have taken action in
reliance upon your authorization before we received your written
revocation;
·
you were required to give
us your authorization as a condition of obtaining coverage;
or
·
if state law gives us the
right to contest a claim under your policy.
The Right to Obtain a
Paper Copy of this Notice:
Upon request, you have the
right to a paper copy of this notice, even if you have agreed to accept this
notice electronically.
How to Contact
Us:
If you have any complaints or
questions about this notice or you want to submit a written request to The Hand
Center of Western Massachusetts as required in any of the previous sections of
this notice, please call
(413) 733-2204 or write to us
at the address below (there will be a standard form to be filled out):
Attention: The Hand Center of
Western Massachusetts Privacy Officer
Address:
The Hand Center of Western Massachusetts
3550 Main St. Suite #204
Springfield, MA 01107
*PHI is individually
identifiable information (including demographic information) relating to your
health, to the health care provided to you or to payment for health care.
THE HAND CENTER OF WESTERN
MASSACHUSETTS
PRIVACY PRACTICES
ACKNOWLEDGEMENT
I have received the
Notice of Privacy Practices and I have been provided an opportunity to review
it.
Patient Name:
____________________________________
Patient DOB: ___________
*If patient is a minor, a
parent or guardian must sign.
Patient Signature:
_________________________________
Chart #: _______________
*Patient,
parent or guardian
Date:
______________________________