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.
Examples of Disclosures
· This facility will generally only disclose medical information about you for purposes of treatment, payment or health care operations.
· Examples of these types of disclosures include, but are not limited to, the following:
o A disclosure of medical information for treatment purposes occurs when we report the results of any diagnostic test to your treating physician who prescribed the test.
o A disclosure of medical information for payment purposes occurs when we submit medical records and bills concerning your treatment to an insurer for payment.
o A disclosure for health care operations purposes occurs when we perform activities such as quality assessment, quality improvement, training programs, credentialing, and clinical guidelines development.
Uses and disclosures for purposes other than treatment, payment, health care operations or those required by law, will not be made without your written authorization. Further, you have the right to revoke any such authorization after giving it.
The Following is a List of Other Uses and Disclosures Allowed by the Privacy Rule
We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you.
Notification – Opportunity to Agree or Object
Unless you object we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Communication with Family - Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.
Your Health Information Rights
The health and billing records we maintain are the physical property of the New England Spine Institute, PC. You have the following rights with respect to your Protected Health Information:
Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office/hospital—we are not required to grant the request but we will comply with any request granted;
Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our facility;
Right to inspect and copy your health record and billing record—you may exercise this right by delivering the request in writing to our facility using the form we provide to you upon request
Right to request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our facility using the form we provide to you upon request. (Please note that we not required to make such amendments); you may file a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
Right to receive an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our facility using the form we provide to you upon request. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
Right to confidential communication by requesting that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office/hospital using the form we give you upon request; and,
If you want to exercise any of the above rights, please contact Matthew H. Kowalski, DC at 225 South Franklin Street, Holbrook, MA 02343 and/or 781-767-5555, in person or in writing, during normal hours. He will provide you with assistance on the steps to take to exercise your rights.
You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and health care operations purposes.
The office is required to:
· M aintain the privacy of your health information as required by law;
· Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
· Abide by the terms of this Notice;
· Request that you sign an acknowledgement that you have received this notice;
· Notify you if we cannot accommodate a requested restriction or request; and
o Accommodate your reasonable requests regarding methods to communicate health information with you.
o Accommodate your request for an accounting of disclosures.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our facility and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Matthew H. Kowalski, DC (President of NESI) at 225 South Franklin Street, Holbrook, MA 02343 and/or 781-767-5555.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Matthew H. Kowalski, DC. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services whose street address is Tommy G. Thompson at The U.S. Department of Health and Human Services – 200 Independence Avenue, S.W. – Washington, DC 20202.
We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office.
We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.
Would you like us to restrict certain information from release? Please complete the following form.
Would you like certain information amended? Please complete the following form.