Women’s Care Center of Memphis, MPLLC

Notice of Privacy Practices for Protected Health Information

Effective Date: April 14, 2003

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 defined as demographic and individually identifiable health information about you that will or may identify you and relates to your past, present and future physical, mental health or condition that involves providing health care services or health care payment.

If you consent, the office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnosis, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Why do you sign an authorization form?
In order to release your protected health information for any reason other than treatment, payment and health care operations, you must sign an authorization that clearly explains how your information will be used.

Note: Information about the following conditions requires an authorization even though release of information is related to treatment, payment or health care operations.

• Alcoholism/drug abuse treatment – Federal Confidentiality 42 CFR Part 2
• Psychotherapy Notes

Examples of use of your health information for treatment purposes are:

Examples of use of your health information for payment purposes:

 Examples of use of your information for Health Care Operations:

 Use of your authorization:
Women’s Care Center of Memphis (WCC) will contractually require our business associates to follow the same confidentiality laws and rules required of WCC, health care providers or health plans. We will not allow others outside WCC and WCC’s business associates to have access to your medical information unless we have the appropriate authorization to do so. Business Associates perform various activities such as billing services, etc. We will provide this Notice and request your acknowledgement of receipt of this Notice and may request your authorization to release information at your first visit. With your authorization, we will release the information that you have approved for release.

Our Responsibilities

The office is required to:

1. Maintain the privacy of your health information as required by law;
2. Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
3. Abide by the terms of the Notice;
4. Notify you if we cannot accommodate a requested restriction or request;
5. Accommodate your reasonable requests regarding methods to communicate health information with you; and
6. Accommodate your request for accounting 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 office and picking up a copy.

Following is a list of other uses and disclosures allowed by the Privacy Rule

Patient Contact - 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. We may contact you as part of a fund-raising effort.

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.

We may use and disclose your protected health information to assist in disaster relief efforts.

When your authorization is not required:

Controlling Disease - As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Child or Elder Abuse & Neglect - We may disclose protected health information to public authorities as allowed by law to report child or elder abuse or neglect.

Food and Drug Administration (FDA) - We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Victims of Abuse, Neglect, or Domestic Violence - We can disclose protected health information to governmental authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment the doctor believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.

Oversight Agencies - Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities to include audits, civil, administrative or criminal investigations: inspections; licensures or disciplinary actions, and for similar reasons related to the administration of healthcare.

Judicial/Administrative Procedures - We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order or administrative tribunal, provided that only the protected health information released is expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process.

Law Enforcement - We may disclose your protected health information for law enforcement purposes as required by law, such as legal processes, including laws that require reporting of certain types of wounds or other physical injury, pertaining to victims or a crime, suspicion that death has occurred as a result of a criminal conduct, in the event that a crime occurs on the premises of the practice, and medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.

Coroners, Medical Examiners and Funeral Directors - We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Organ Procurement Organizations - Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.

Research - We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Threat to Health and Safety - To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

Correctional Institutions - If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.

Military Activity and National Security – When appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel for (1) activities deemed necessary by appropriate military command authorities; (2) the purpose of a determination by the Department of Veteran Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protected services to the President or others legally authorized.

Workers Compensation - If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Other Uses and Disclosures - Other uses and disclosures besides those identified in the Notice will be made only as otherwise authorized by law or with your written authorization which you may revoke except to the extent information or actions have already been taken. Under the law, we must make disclosures to you and when required by Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of federal law.

Your Health Information Rights

The health and billing records we maintain are the property of the physician’s office. You have the following rights with respect to your Protected Health Information:

1. You have a right to request restrictions regarding how we use and disclose your Protected Health Information regarding treatment, payment, health care operations, however we are not required to agree to your restrictions. If we do agree to your requested restriction, we will follow your request, unless you are in need of emergency treatment, and the information is needed to provide emergency care. However, your restriction (if agreed to) will not prevent us from releasing information as required by other state and federal laws. If we accept your restrictions, we have the right to terminate them by notifying your of such.
2. You do not have to sign an authorization form, however, it may prevent us from completing a task you have requested such as enrollment in a research study.
3. Refusal to sign an authorization form will not be held against you.
4. You may change your mind and revoke your authorization, except inasmuch as we have relied on the authorization until that point or if the authorization was obtained as a condition of obtaining insurance coverage.
5. You may obtain a paper copy of the Notice of Privacy Practices for Protected Health Information (“Notice”) by making a request at our office. Material revisions to this Notice will be made available to you within 60 days.
6. You have a right to inspect and copy your protected health information as permitted by law.
7. You have a right to request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request. (The physician or other health care provider is 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.
8. You have a 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 office using the form we provide to you upon request.
9. You have a 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 using the form we give you upon request.

If you want to exercise any of the above rights, please contact Nina Wolfe at 901-763-2212 in person during normal business hours, or in writing at 6215 Humphreys Blvd, Suite 501, Memphis, TN 38120. She 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 authorization to use and disclose your protected health information for treatment, payment, and health care operations.

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 Nina Wolfe, Executive Director, (901) 763-2212.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint with our office by delivering the written complaint to Nina Wolfe. You may also file a complaint by e-mailing it to OCRMail@hhs.gov.

• 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.