NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
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.
Family Planning Specialists Medical Group, Inc. (“FPS”) is committed to protecting the privacy of your health record and the confidentiality of your visit. Your healthcare record, known as a chart, and the information it contains will not be disclosed to any one or any agency outside of FPS without written authorization from you unless such a release is required by law.
FPS will use your health information for the purpose of:
For example, information obtained by a healthcare provider or staff member will be recorded in your record and used to determine the best course of treatment for you.
For example, a bill may be sent to you or to a third party payer. The information on the bill may include information that identifies you, as well as your diagnosis, procedure, and supplies used.
Regular Healthcare Operations
For example, members of the medical staff or the quality improvement/risk management staff may use information in your health record to assess the care you received and outcomes of your care. This information will then be used in the Continuous Quality Improvement program of FPS.
FPS provides some services through contracts with business associates. An example is a laboratory. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Disclosures required by law:
Food and Drug Administration (FDA)
As required by law, FPS may disclose to the Food and Drug Administration (FDA) health information relative to adverse events with respect to product defects, product recalls, repairs or replacement.
FPS may disclose your health information, as required by law, to public health or legal authorities charged with preventing or controlling disease, injury or disability.
FPS may disclose health information for law enforcement purposed as required by law or in response to a valid subpoena.
Your Health Information Rights
Although your health record is the physical property of FPS, the information it contains belongs to you. You have the right to:
- Request a restriction on certain uses and disclosures of your information
- Obtain a paper copy of the notice of information practices upon request
- Inspect a copy of your health record
- Amend your health record as provided in 45 CFR 164.528
- Obtain an accounting of disclosures of your health information
- Request communication of your health information by alternative means or at alternative locations
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken
FPS is required to:
- Maintain the privacy of your health information
- Provide you with a notice as to FPS’ legal duties and privacy practices with respect to information FPS collects and maintains about you
- Abide by the terms of this notice
- Notify you if FPS is unable to agree to a requested restriction
- Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
FPS reserves the right to change practices and to make the new provisions effective for all protected health information FPS maintains. Should FPS’ information practices change, we will make a reasonable effort to notify you of this change.
For More Information or to Report a Problem
If you have questions, or if you want to report a problem, please contact Tammy, FPS’ Privacy Officer at 510-268-3720. Complaints may also be filed with the Secretary of Health and Human Services, an act for which no retaliation will occur.
I have read this privacy notice and I have been given ample time to ask questions regarding the information it contains. I understand Family Planning Specialists will hold my record to the highest standard of privacy and confidentiality and will only release my personal health information when so authorized by me in writing, or when required by law to do so.
RIGHTS OF PATIENTS
- It is the policy of Family Planning Specialists to treat each patient with respect, consideration, and dignity. This shall apply to every aspect of the patient’s care.
- Care is given in a manner that protects each patient’s privacy to the greatest extent possible.
- All information regarding each patient, including medical records and personal information, will be kept strictly confidential. No information regarding any patient will be released without that patient’s written consent. All staff members are bound by confidentiality.
- Family Planning Specialists will, to the extent possible, provide patients with complete information regarding their diagnosis and treatment. Appropriate referrals will be given to patients who need services not available at Family Planning Specialists.
- Patients are encouraged to ask questions and to participate in decisions regarding their care.
- Family Planning Specialists will provide patients with accurate information regarding fees and payment options. Family Planning Specialists does not advertise its services in a manner that is misleading to patients.
- Patients have the right to refuse to participate in experimental research.
- Patients have the right to know the name of the physician primarily responsible for their care.
- Patients have the right to receive sufficient information regarding any proposed procedure or treatment so that they are able to give informed consent.
- Patients have the right to have their complaints and concerns addressed and to receive appropriate responses.
RESPONSIBILITIES OF PATIENTS
- In order to provide patients with the best possible service, it is necessary to have a complete and accurate medical history.
- Patients are requested to take responsibility for their own health by seeking follow up care from Family Planning Specialists or another facility, if necessary, and by complying with the advice of Family Planning Specialists physicians.
- Patients are responsible for paying the full cost of services received or securing the necessary referral from their health plan and paying any deductible or copayment at the time services are received.
- Actual or implied threats against Family Planning Specialists staff or patients will not be tolerated.