COMMUNITY HEALTH CLINIC OLE

SISTER ANN DENTAL CLINIC

HEALTHY MOMS & BABIES

(v 08/27/09)

Notice of Privacy Practices

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS CLINIC) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR PHI.

Please review this notice carefully.

USE AND DISCLOSURE OF HEALTH INFORMATION

Community Health Clinic Ole, Sister Ann Dental Clinic, and Healthy Moms and Babies (“Clinic”) may use your health information, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care, and conducting health care operations. The Clinic has established policies to guard against unnecessary disclosure of your health information, or “PHI.”

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Provide Treatment. The Clinic may use your health information to coordinate care within the Clinic and with other involved in your care, such as your primary care physician, members of the Clinic provider team and other professionals who are involved in coordinating your care. For example, your Clinic health care providers will need information about your symptoms to prescribe appropriate medications. The Clinic may also disclose your PHI to individuals outside of the Clinic involved in your care including others who assist in your care such as family members, pharmacists, hospitals, the state vaccine registry, or other health care professionals.

To Obtain Payment. The Clinic may include your health information in order to bill and collect payment from third parties such as insurers and family guarantors, or the primary insured family member for items and services you receive from us. We may contact your health insurer to certify that you are eligible for benefits (and scope of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, treatment. We may also disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

To Conduct Health Care Operations. The Clinic may use and disclose health information for its own operations in order to facilitate the function of the Clinic and as necessary to provide quality care to all of the Clinic’s patients. Health Care Operations includes such activities as:

• Quality assessment and improvement activities.
• Activities designed to improve health or reduce health care costs.
• Protocol development, case management and care coordination.
• Contacting health care providers and patients with information about treatment options, alternatives and other related functions that do not include treatment.
• Health-related benefits and services.
• Professional review and performance evaluation.
• Training programs including those in which students, trainees, or practitioners in health care learn under supervision.
• Accreditation, certification, licensing or credentialing activities.
• Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
• Business planning and development including cost management and planning related analyses and formulary development.
• Business management and general administrative activities of the Clinic.
• Fundraising for the benefit of the Clinic.
• Appointment reminders.

For example, the Clinic may use your health information to evaluate its staff performance, combine your health information with other Clinic patients in evaluating how to more effectively serve all Clinic patients, disclose your health information to Clinic staff and contracted personnel for training purposes, use your health information to contact you as a reminder regarding an upcoming appointment, or contact you as a part of general fundraising and other community information mailings (unless you tell us you do not want to be contacted).

For Appointment Reminders. The Clinic may use and disclose your health information to contact you as a reminder that you have an appointment for an office visit or procedure.

For Treatment Options & Alternatives. The Clinic may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY ALSO BE USED AND DISCLOSED:

When Legally Required. The Clinic will disclose your health information when it is required to do so by any Federal, State or Local law.

When There are Risks to Public Health. The Clinic may disclose your health information for public activities and purposes in order to:

• Prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions.
• Report adverse events, product defects, to track products or enable product recalls, repairs and replacements, and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.
• Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
• Notify an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect or Domestic Violence. The Clinic is allowed to notify government authorities if the Clinic believes a patient is the victim of abuse, neglect or domestic violence. The Clinic will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.

To Conduct Health Oversight Activities. The Clinic may disclose your health information to a health oversight Agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. The Clinic, however, may not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care of public benefits.

In Connection with Judicial and Administrative Proceedings. As permitted or required by State law, the Clinic may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:

• As required by law for reporting of certain types of wounds or other physical injuries pursuant to a court order, warrant subpoena or summons or similar process.
• For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
• Under certain limited circumstances, when you are the victim of a crime.
• To a law enforcement official if the Clinic has a suspicion that your death was the result of criminal conduct including criminal conduct at the Clinic.
• In an emergency to report a crime.

To Coroners and Medical Examiners. If necessary to carry out their duties, the Clinic may disclose your health information to a medical examiner or coroner to identify a deceased individual or for purposes of determining your cause of death or for other duties, as authorized by law.

To Funeral Directors. The Clinic may release information in order for funeral directors to carry out their duties, as authorized by law.

For Organ, Eye or Tissue Donation. The Clinic may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eye or tissue for the purpose of facilitating the donation and transplantation.

For Research Purposes. The Clinic may, under very select circumstances, use your health information for research. Before the Clinic discloses any of your health information for such research purposes, projects will be subjected to an extensive approval process. We will obtain your written authorization to use your PHI for research purposes except when an Internal Review Board or Privacy board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the PHI will not be reused or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.

In the Event of a Serious Threat to Health or Safety. The Clinic may, consistent with applicable and ethical standards of conduct, disclose your health information if the Clinic, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety, or the health and safety of the public.

For Specified Government Functions. In certain circumstances, the Federal regulations authorize the Clinic to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others for medical suitability determinations, including inmates and law enforcement custody.

For Worker’s Compensation: The Clinic may release your health information for a worker’s compensation or other similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than stated above, the Clinic will not disclose your health information other than with your written authorization. If you or your representative authorizes the Clinic to use or disclose your health information, you may revoke that authorization in writing at any time.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

You have the following rights regarding your health information that the Clinic maintains:

Right to request restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on the Clinic’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, the Clinic is not required to agree to your request. If you wish to make a request for restrictions, you must make a written request to:

Your request must describe in a clear and concise fashion:

• The information you wish restricted;
• Whether you are requesting to limit our practice’s use, disclosure or both; and
• To whom you want the limits to apply

Right to receive confidential communications. You have the right to request that the Clinic communicate with you in a certain way. For example, you may ask that the Clinic only conduct communications pertaining to your health information with your privately with no other family members present. If you wish to receive confidential communications, please write the Corporate Compliance Officer at the address listed above. The Clinic will not request you provide reasons for your request, and will attempt to honor your reasonable requests for confidential communications.

Right to inspect and copy your health information. You have the right to inspect and copy your health information, including billing records, with specific limitations as prescribed by HIPAA. You must submit your request in writing to the Corporate Compliance Officer at the address listed above. If you request a copy of your health information, the Clinic may charge a reasonable fee for copying and assembling costs associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

Right to amend health care information. You or your representative have the right to request that the Clinic amend your records, if you believe that your health information is incorrect or incomplete. That request may be made for as long as the information is maintained by the Clinic. A request for an amendment of records must be made in writing to the Corporate Compliance Officer at the address listed above. The Clinic may deny the request if it is not in writing or does not include a reason for the amendment The request may also be denied if your health information records were not created by the Clinic, if the records you’re requesting are not part of the Clinic’s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of the Clinic, the records containing your health information are accurate and complete.

Right to an accounting. You or your representative have the right to request an accounting of disclosures of your health information made by the Clinic for certain reasons, including reasons related to public purposes authorized by law and certain research. The request for an accounting must be made in writing to the Community Health Clinic Ole Medical Records Manager at the address listed above. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years from date of disclosure and may not include any dates prior to April 13, 2003. The Clinic would provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. The Clinic will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Right to a paper copy of this notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please request a copy from a Community Health Clinic Ole Receptionist.

DUTIES OF THE CLINIC

The Clinic is required by law to maintain the privacy of your health information and to provide you and your representative of this Notice of its duties and privacy practices. The Clinic is required to abide by the terms of this Notice as may be amended from time to time. The Clinic reserves the right to change the terms of its Notice and make the new Notice provisions effective for all health information that it maintains. If the Clinic changes its Notice, the Clinic will provide a copy of the revised Notice to your or your appointed representative. You or your personal representative have the right to express complaints to the Clinic to the Clinic and to the Secretary of the Department of Health and Human Services if you or your representative believe your privacy rights have been violated. Any complaints to the Clinic should be made in writing to the Corporate Compliance Officer at the address listed above. The Clinic encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

This Notice is effective April 14, 2003.

If you have any questions regarding this policy, please call (707) 254-1770.