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.
Maple Street Medical, (“MSM”) is dedicated to maintaining the privacy of your personal health information. In providing care to you, we will create records regarding you and the treatment and services we provide. We are required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the HIPAA Omnibus Final Rule of January, 2013 to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and MSM privacy practices.
USES AND DISCLOSERS FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS:
I. TREATMENT: MSM may use and disclose your health information to coordinate care within MSM and disclose your health information to others involved in your care, such as your attending physician, your primary family caregiver, pharmacists, suppliers of medical equipment, or other health care professionals.
2. PAYMENT: MSM may use and disclose your health information for billing and payment purposes or for the billing and payment needs of other health care providers. For example, MSM may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or MSM. MSM also may need to obtain prior approval from your insurer and may need to explain to the insurer why MSM is seeking certain services and procedures.
3. HEALTH CARE OPERATIONS: MSM may use and disclose health information for its own operations to facilitate the function of MSM and as necessary to provide quality care to all of our patients. Health care operations include such activities as quality improvement, cost containment, case management activities, performance evaluation, training of employees and students, accreditation, auditing and business planning, and compliance and quality assurance purposes.
SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
APPOINTMENT REMINDERS: MSM may use and disclose your personal health information to contact you at home or at work to remind you of appointments. MSM may leave a message with the person or answering machine at those locations. MSM may also send postcards in the mail to remind you of annual visits that are due.
TREATMENT ALTERNATIVES: Subject to certain limitations, MSM 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.
DISCLOSURES REQUIRED BY LAW: MSM will use and disclose your personal health information when we are required to do so by federal, state or local law.
INDIVIDUALS INVOLVED IN YOUR CARE: Unless you object, MSM may disclose your health information to a family member, close personal friend or other person you identify, including clergy, who is involved in your care.
BUSINESS ASSOCIATES: MSM business associates are individuals and organizations that carry out functions or activities on our behalf that involve health information. MSM may disclose your health information to a business associate who needs the information to perform services for or on behalf of us. MSM business associates have agreed to preserve the confidentiality of this information and are directly liable for compliance with HIPAA requirements. Business associates are not, however, defined as conduits of personal health information, such as internet service providers or a courier service.
PUBLIC HEALTH ACTIVITIES: MSM may disclose your health information for public health activities in order to prevent or control disease, report disease or death, or report adverse events with products or medication, for example.
REPORT ABUSE, NEGLECT, OR DOMESTIC VIOLENCE: If MSM believes that you have been a victim of abuse, neglect or domestic violence, MSM may use and disclose your health information to notify a government authority if authorized by law or if you agree to the report.
CONDUCT HEALTH OVERSIGHT ACTIVITIES: MSM may disclose your health information to a health oversight for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action and for activities involving government oversight of the health care system.
CONNECTION TO JUDICIAL OR ADMINISTRATIVE PROCEEDINGS: MSM may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only if certain conditions are met.
LAW ENFORCEMENT PURPOSES: MSM may disclose your health information to a law enforcement official for certain law enforcement purposes, including, for example, to comply with reporting requirements; to comply with a court order, warrant, or similar legal process; or to respond to certain requests for information concerning crimes.
CORONERS AND MEDICAL EXAMINERS: MSM may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by and consistent with law, and as necessary to carry out the duties of Funeral Directors with respect to your funeral arrangements.
ORGAN, EYE OR TISSUE DONATION: When directed, MSM may use and disclose your 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 facilitating the donation and transplantation.
RESEARCH PURPOSES: MSM may, under very select circumstances, use and disclose your health information for research purposes if the privacy aspects of the research have been reviewed and approved, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.
AVERT A SERIOUS THREAT TO HEALTH OR SAFETY: When necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health or safety of the public or another person, MSM may use and disclose your health information, limiting disclosures to a person or persons reasonably able to help lessen or prevent the threat.
SPECIALIZED GOVERNMENT FUNCTIONS: If you are a member of the armed forces, MSM may use and disclose your health information as required by military command authorities. MSM may disclose your health information for national security purposes or as needed to protect the President of the United States or certain other officials or to conduct certain special investigations.
DISASTER RELIEF: MSM may disclose limited health information about you to a disaster relief organization.
CONNECTION WITH LAW ENFORCEMENT CUSTODY: If you are under the custody of a law enforcement official or a correctional institution, MSM may disclose your health information to the institution or official for certain purposes including the health and safety of you and others.
WORKER’S COMPENSATION: MSM may use and disclose your health information to comply with laws relating to worker’s compensation or similar programs.
USES AND DISCLOSURES WITH YOUR AUTHORIZATION
Other than as stated above, MSM will not use or disclose your health information without your written authorization. Unless otherwise stated, releases are valid for only six months. If you or your representative authorizes MSM to use or disclose your health information, you may revoke that authorization in writing at any time. If you revoke an Authorization, MSM will no longer use or disclose your health information for the purposes covered by that Authorization, except where MSM has already relied on the Authorization.
MSM will notify you and the Department of Health and Human Services of any unauthorized acquisition, access, use, or disclosure of your unsecured medical information that presents a significant risk of financial, reputational, or other harm to you to the extent required by law. Unsecured medical information means medical information not secured by technology that renders the information unusable, unreadable, or indecipherable as required by law. Business associates that experience a breach must provide notice of breach of unsecured personal health information to MSM “without unreasonable delay and in no case later than 60 days following the discovery of a breach.”
YOUR RIGHTS REGARDING YOUR PERSONAL HEALTH INFORMATION:
l. You have the right to confidential communication as provided by §164.522.
2. You have the right to request restrictions on disclosure as provided by §164.522.
3. You have the right to authorize other uses or disclosures.
4. You have the right to request inspection and a copy of your information as provided by §164.524.
5. You have the right to request corrections to your information as provided by §164.526.
6. You have the right to restrict disclosure of information to health plans for services you paid out-of-pocket.
7. You have the right to opt-out of fundraising and marketing communications.
8. You have the right to a copy of this notice.
9. You have the right to report a privacy violation of your information.
CHANGES TO THIS NOTICE
MSM reserves the right to change the terms of this Notice and to make the revised or new Notice provisions effective for all health information already received and maintained by MSM as well as for all health information MSM receives in the future. MSM will provide a copy of the revised Notice upon request.
FOR FURTHER INFORMATION OR TO FILE A COMPLAINT
You have the right to express complaints to MSM and to the Office for Civil Rights in the U.S. Department of Health and Human Services (“OCR”) if you believe that your privacy rights have been violated. Any complaints to MSM should be made in writing to the Privacy Officer at the address below. MSM 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. MSM has designated the Privacy Officer as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. Complaints against MSM can be mailed to Privacy Officer, Maple Street Medical, 281 Maple St., East Longmeadow, MA, 01028. To file a complaint with OCR, send your written complaint by mail to Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201 or by email to [email protected] If you have any questions regarding this Notice, please call us at 413-525-5160. This Notice is effective February 26, 2013. Rev 2/26/13