Notice of Privacy Practices for Jackson Siegelbaum Gastroenterology
effective july 1, 2006
This notice describes how medical information about you may be used and disclosed and how to get access to this information.
Please read it carefully.
If you have any questions regarding this notice, you may contact our privacy officer at:
Address: Jackson Siegelbaum Gastroenterology
Attention: Privacy Officer
423 N 21st St.
Ste 100, Camp Hill, PA
- YOUR PROTECTED HEALTH INFORMATION
Jackson Siegelbaum Gastroenterology is required by the federal privacy rule to maintain the privacy of health information protected by the rule. We are also required to provide you with notice of our legal duties and privacy practices related to your protected health care information. We are required to abide by the terms of the notice currently in effect.
Your protected health information includes the following: (a) information that relates to your past, present or future physical or mental health or condition; (b) the provision of health care to you; and (c) payment for health care provided to you. Protected information must individually identify you or can reasonably be used to identify you.
Your medical and billing records at our practice are examples of information that is usually regarded as protected health information.
- USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
- Treatment, payment, and health care operations
This section describes how we may use and disclose your protected health information for treatment, payment and health care operations purposes. The descriptions include examples. Not every possible use or disclosure for treatment, payment and health care operations purposes will be listed.
We may use and disclose your protected health information for our treatment purposes as well as the treatment purposes of other health care providers. Treatment includes the provision, coordination, or management of health care services to you by one or more health care providers.
Some examples of treatment issues and disclosures include:
- During an office visit, practice physicians and other staff involved in your care may review your medical record and share and discuss your medical information with each other.
- We may share and discuss your medical information with an outside physician to whom we have referred your care.
- We may share and discuss your medical information with an outside physician with whom we are consulting regarding your care.
- We may share and discuss your medical information with an outside laboratory, radiology center, or other health care facility where we have referred you for testing.
- We may share and discuss your medical information with an outside home health agency, durable medical equipment agency or other health care provider to whom we have referred you for health care services and products.
- We may share and discuss your medical information with a hospital or other health care facility where we are admitting or treating you.
- We may share and discuss your medical information with another health care provider who seeks this information for the purpose of treating you. This may be done by personal conversation, telephone conversation, written correspondence mailed to the health care provider and by facsimile transmission.
- We may use a patient sign-in sheet in the waiting area that is accessible to all patients.
- We may page patients in the waiting room when it is time for them to go to an examining room. To do this, we may use your first and/or last name.
- We may contact you to provide appointment reminders. To do this, we may send postcards with our practice name and return address, mail you letters in envelopes with our practice name and return address, call you at home or work, or leave messages with family members or voice mail.
- We may contact you to call the office. To do this, we may send postcards with our practice name and return address, mail you letters in envelopes with our practice name and return address, call you at home or work, or leave messages with family members or voice mail.
We may use and disclose your protected health information for our payment purposes as well as the payment purposes of other health care providers and health plans. Payment uses and disclosures include activities conducted to obtain payment for the care provided to you or so you can obtain reimbursement for that care, for example, from your health insurer.
Some examples of payment uses and disclosures include:
- Sharing information with you health insurer to determine whether you are eligible for coverage or whether proposed treatment is a covered service.
- Submission of a claim form to your health insurer.
- Providing supplemental information to you health insurer so that you health insurer can obtain reimbursement from another health plan under a coordination of benefits clause in your subscriber agreement.
- Sharing your demographic information (for example, your address) with other health care providers who seek this information to obtain payment for health care services provided to you.
- Mailing you bills in envelopes with our practice name and return address.
- Providing a bill to a family member or other person designated as responsible for payment for services rendered to you.
- Providing medical records and other documentation to your health insurer to support the medical necessity of a health service.
- Allowing your health insurer access to your medical record for a medical necessity or quality review audit.
- Providing consumer-reporting agencies with credit information (you name and address, date of birth, social security number, payment history, account number, and our name and address.
- Providing information to a collection agency or our attorney for purposes of securing payment of a delinquent account.
- Disclosing information in a legal action for purposes of securing payment of a delinquent account.
- Health care operations
We may use and disclose your protected health information for our health care operation purposes as well as certain health care operation purposes of other health care providers and health plans.
Some examples of health care operation purposes include:
- Quality assessment and improvement activities.
- Population based activities relating to improving health or reducing health care costs.
- Reviewing the competence, qualifications, or performance of health care professionals.
- Conducting training programs for medical and other students.
- Accreditation, certification, licensing, and credentialing activities.
- Health care fraud and abuse detection and compliance programs.
- Conducting other medical review, legal services, and auditing functions.
- Business planning and development activities, such as conducting cost management and planning related analyses.
- Sharing information regarding patients with entities that are interested in joining our practice.
- Other business management and general administrative activities, such as compliance with the federal privacy rule and resolution of patient grievances.
- Uses and disclosures for other purposes
We may use and disclose your protected health information for other purposes. This section describes those purposes by category. Each category lists one or more examples. Not every use or disclosure in a category will be listed. Some examples fall into more than one category – not just the category under which they are listed.
- Individuals involved in care or payment for care
We may disclose your protected health information to someone involved in your care or payment for your care, such as spouse, a family member, or close friend. For example, if you have surgery, we may discuss your physical limitations with a family member assisting in your post-operative care.
- Notification purposes
We may use and disclose your protected health information to notify, or to assist in the notification of, a family member, a personal representative, or another person responsible for your care, regarding your location, general condition, or death. For example, if you are hospitalized, we may notify a family member of the hospital and your general condition. In addition, we may disclose your protected health information to a disaster relief entity, such as the Red Cross, so that it can notify a family member, a personal representative, or another person involved in your care regarding your location, general condition, or death.
- Required by law
We may use and disclose protected health information when required by federal, state, or local law. For example, we may disclose protected health information to comply with mandatory reporting requirements involving births and deaths, child abuse, disease prevention and control, vaccine-related injuries, medical device-related deaths and serious injuries, gunshot and other injuries by a deadly weapon or criminal act, driving impairments, blood alcohol testing and medical errors.
- Other public health activities We may use and disclose protected health information for public health activities, including:
- Communicable disease reports.
- Child abuse and neglect reports.
- FDA-related reports and disclosures, for example, adverse event reports
- Public health warnings to third parties at risk of a communicable disease or condition.
- OSHA requirements for workplace surveillance and injury reports.
- Victims of abuse, neglect or domestic violence
We may use and disclose protected health information for purposes of reporting abuse, neglect or domestic violence in addition to child abuse. For example, reports of elder abuse to the Department of Aging or abuse of a nursing home patient to the Department of Public Welfare.
- Health oversight activities
We may use and disclose protected health information for purposes of health oversight activities authorized by law. These activities could include audits, inspections, investigations, licensure actions, and legal proceedings. For example, we may comply with a Drug Enforcement Agency inspection of patient records.
- Judicial and administrative proceedings
We may use and disclose protected health information in judicial and administrative proceedings in response to a court or subpoena, discovery request or other lawful process. For example, we may comply with a court order to testify in a case at which your medical condition is at issue.
- Law enforcement purposes
We may use and disclose protected health information for certain law enforcement purposes including to:
- Comply with legal process, for example, a search warrant.
- Comply with a legal requirement, for example, mandatory reporting of gun shot wounds.
- Respond to a request for information for identification/location purposes.
- Respond to a request for information about a crime victim.
- Report a death suspected to have resulted from criminal activity.
- Provide information regarding a crime on the premises.
- Report a crime in an emergency.
- Coroners and medical examiners
We may use and disclose protected health information for purposes of providing information to a coroner or medical examiner to identify a deceased patient, determine a cause of death, or facilitate their performance of other duties required by law.
- Funeral directors
We may use and disclose protected health information for purposes of providing information to funeral directors as necessary to carry out their duties.
- Organ and tissue donation
We may use and disclose protected health information to facilitate organ, eye and tissue donation and transplantation. Information may be provided to entities engaged in procurement, banking, or transplantation of cadaveric organs, eyes, or tissue.
- Threat to public safety
We may use and disclose protected health information for purposes involving a threat to public safety including protection of a third party from harm and identification and apprehension of a criminal. For example, in certain circumstances, we are required by law to disclose information to protect someone from imminent serious harm.
- Specialized government functions
We may use and disclose protected health information for purposes involving specialized government functions including:
- Military and veterans activities.
- National security and intelligence.
- Protective service for the President and others.
- Medical suitability determinations for the Department of State.
- Correctional institutions and other law enforcement custodial situations.
- Workers’ compensation and similar programs
We may use and disclose protected health information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault. For example, this would include submitting a claim for payment to your employer’s workers’ compensation carrier if we treat you for a work injury.
- Business associates
A business associate, such as a billing company, an accountant firm, or a law firm, performs certain functions of the practice. We may disclose protected health information to our business associates and allow them to create and receive protected health information on our behalf. For example, we may share with a billing company information regarding your care and payment for your care so the company can file health insurance claims and bill you or another responsible party.
- Creation of de-identified information
We may use protected health information about you in the process of de-identifying the information. For example, we may use your protected health information in the process of removing those aspects that could identify you so that the information can be disclosed to a researcher without your authorization.
- Incidental disclosures
We may disclose protected health information as a by-product of an otherwise permitted use or disclosure. For example, other patients may overhear your name being called in the waiting room.
- Individuals involved in care or payment for care
- Uses and disclosures with authorization
For all other purposes that do not fall under a category listed under sections III.A and III.B, we will obtain your written authorization to use or disclose your protected health information. Your authorization can be revoked at any time except to the extent that we have relied on the authorization.
- Treatment, payment, and health care operations
- PATIENT PRIVACY RIGHTS
- Further restriction on use or disclosure
You have the right to request that we further restrict use and disclosure of your protected health information to carry out treatment, payment, or health care operations, to someone who is involved in your care or the payment for your care, or for notification purposes.
To request a further restriction, you must submit a written request to our privacy officer. The request must state: (a) what information you want restricted; (b) how you want the information restricted; and (c) to whom you want the restriction to apply.
- Confidential communication
You have the right to request that we communicate your protected health information to you by a certain means or at a certain location. For example, you might request that we only contact you by mail or at work. We are not required to agree to requests for confidential communications that are unreasonable.
To request confidential communication, you must submit a written request to our privacy officer. The request must state how and where you want to be contacted. In addition, if another individual or entity is responsible for payment, the request must explain how payment will be handled.
- Accounting of disclosures
You have the right to obtain, upon request, and “accounting” of certain disclosures of your protected health information by us (or a business associate for us). This right is limited to disclosures within six years of the request and other limitations. We may charge you for providing the accounting.
To request an accounting, you must submit a written request to our privacy officer. The request should designate the applicable time period.
- Inspection and copying
You have the right to inspect and obtain a copy of your protected health information that we maintain in a designated records set (medical record). This right is subject to limitations. We may charge you for the labor and supplies involved in providing the copies.
To request access to your medical record, you must submit a written request to our privacy officer. The request must: (a) describe the health information to which access is requested; (b) state how you want to access the information such as inspection, pick-up of copy, mailing of copy; (c) specify any requested form or format such as paper copy or an electronic means; and (d) include the mailing address, if applicable.
- Right to amendment
You have the right to request that we amend protected health information that we maintain about you in a designated records set (medical record) if the information is incorrect or incomplete. This right is subject to limitations.
To request an amendment, you must submit a written request to our privacy officer. The request must specify each change that you want and provide a reason to support each requested change.
- Paper copy of privacy notice
You have the right to receive, upon request, a paper copy of our Notice of Privacy Practices. To obtain a paper copy, contact our privacy officer.
- Further restriction on use or disclosure
- CHANGES TO THIS NOTICE
We reserve the right to change this notice at any time. We further reserve the right to make any change effective for all protected health information that we maintain at the time of the change – including information that we created or received prior to the effective date of the change. We will provide a copy of our current notice in the waiting room for the practice. At any time, patients may review the current notice by contacting our privacy officer. Patients may also access the current notice at our web site at www.gicare.com.
If you believe that we have violated your privacy rights, you may submit a complaint to the privacy officer of Jackson Siegelbaum Gastroenterology or to the Secretary of Health and Human Services. Submit the complaint in writing. We will not retaliate against you for filing a complaint.
- LEGAL EFFECT OF THIS NOTICE
This notice is not intended to create contractual or other rights independent of those created in the federal privacy rule.