Blue Springs
205 NW R.D. Mize Rd.
Suite 304
Blue Springs, MO 64014
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Independence
11200 Winner Road
Independence, MO 64052
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Higginsville
1717 N. Main Street
Higginsville, MO  64037
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Appointments: (816) 655-0102
Phone:  (816) 228-4770
Fax:  (816) 228-1156
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Notice of Privacy Practices

 

Cockerell & McIntosh Pediatrics, P.C.

 

(Effective Date of September 1, 2013)

 

 

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.

 

A.    OUR COMMITMENT TO YOUR PRIVACY

 

Our practice is dedicated to maintaining the privacy of your medical information.  In conducting our business, we will create records regarding you and the treatment and services we provide to you.  We are required by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") to maintain the confidentiality of certain medical information known as protected health information, or PHI.  PHI is individually identifiable health information, including demographic information, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a health plan that relates to:

 

·         Your past, present or future physical or mental health or condition;

·         The provision of health care to you; or

·         The past, present or future payment for the provision of health care to you.

 

We are required by HIPAA to provide you with this Notice of Privacy Practices ("Notice") that discusses our legal duties and the privacy practices that we maintain in our practice concerning your PHI.  By law, we must follow the terms of the Notice that we have in effect at the time.

 

We are required by law to provide you with the following important information:

 

·         How we may use and disclose your PHI;

·         Your privacy rights in your PHI; and

·         Our obligations concerning the use and disclosure of your PHI.

 

The terms of this Notice apply to all records containing your PHI that are created or retained by our practice.  We reserve the right to revise or amend this Notice.  Any revision or amendment to this Notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future.  Our practice will post a copy of our current Notice on our website at www.cmpeds.com and in our offices in a visible location at all times, and you may request an electronic or paper copy of our most current Notice at any time.

 

B.    IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

 

[Privacy Officer, 205 West R.D. Mize Road, Suite 304, Blue Springs, MO 64014, (816) 228-4770.]

 

C.    WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS:

 

Under the law, we may use or disclose your PHI under certain circumstances without your permission.  The following categories describe the different ways in which we may use and disclose your PHI.

 

  1. Treatment.  Our practice may use your PHI to treat you.  For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis.  We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you.  Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment.  We may also disclose your PHI to other health care providers for purposes related to your treatment.

 

  1. Payment.  Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us.  For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We may also disclose your PHI to other health care providers and entities to assist in their billing and collecting efforts. 

 

  1. Health Care Operations.  Our practice may use and disclose your PHI to operate our business.  As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost management and business planning activities for our practice.  We may also disclose your PHI to other health care providers and entities to assist in their health care operations.

 

  1. Business Associates.  Our practice may contract with individuals or entities known as "business associates" to perform various functions on our behalf or to provide certain types of services.  In order to perform these functions or provide these services, business associates will receive, create, use and/or disclose your PHI, but only after they agree in writing with us to implement appropriate safeguards regarding your PHI.  For example, we may disclose your PHI to a business associate to administer claims or provide support services, but only after the business associate enters into a business associate contract with us.

 

  1. Treatment Options.  Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.

 

  1. Health-Related Benefits and Services.  Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you. 

 

  1. Release of Information to Others Involved in Your Care.  Our practice may release your PHI to a friend or family member whom you have identified as being  involved in your care, or who assists in taking care of you.  If you are not present, we may disclose only the PHI that is directly related to the person's involvement with your care. We may also use or disclose your PHI to help notify this person of your location, general condition, or death.

 

  1. To You.  When you request, our practice is required to disclose to you the medical records and billing records about you that are maintained by or for us.  

 

D.   WE MAY ALSO USE AND DISCLOSE YOUR PHI IN OTHER PERMITTED CIRCUMSTANCES:

 

In addition to the above, the following categories describe more possible scenarios in which we may use or disclose your PHI:

 

  1. Disclosures Required by Law.  Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

 

  1. Public Health Activities.  Our practice may disclose your PHI for public health actions.  These actions generally include the following:

 

·        maintaining vital records, such as births and deaths

·        reporting child abuse or neglect

·        preventing or controlling disease, injury or disability

·        notifying a person regarding potential exposure to a communicable disease

·        notifying a person regarding a potential risk for contracting of spreading a disease or condition

·        reporting reactions to drugs or problems with products or devices

·        notifying individuals if a product or device they may be using has been recalled

·        notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

 

  1. Disclosures about Abuse, Neglect, and Domestic Violence.  Our practice may disclose your PHI in notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an individual (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information

 

  1. Health Oversight Activities.  Our practice may disclose your PHI to a health oversight agency for activities authorized by law.  Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure or disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

 

  1. Judicial and Administrative Proceedings.  If you are involved in a lawsuit or similar proceeding, our practice may use and disclose your PHI in response to a court or administrative order.  We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. 

 

  1. Law Enforcement.  We may disclose PHI if asked to do so by a law enforcement official: 

 

·         Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement

·         Concerning a death we believe has resulted from criminal conduct

·         Regarding criminal conduct at our offices

·         In response to a warrant, summons, court order, subpoena or similar legal process

·         To identify or locate a suspect material witness, fugitive or missing person

·         In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

           

7.   Deceased Individuals.  Our practice may disclose PHI to a medical examiner or coroner to identify a deceased individual, to identify the cause of death, or other duties as authorized by law.  We also may release information to funeral directors as necessary to perform their jobs.

 

  1. Organ and Tissue Donation.  Our practice may use and disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating organ, eye or tissue donation or transplantation.

 

9.   Research.  Our practice may use and disclose your PHI for research purposes in certain limited circumstances.  We will obtain your written authorization to use your PHI for research purposes except in the following circumstances:

 

·        When the individual identifiers have been removed; or

·        When an institutional review board or privacy board has reviewed the research proposal and established protocols to ensure the privacy of the requested information, and approves the research.

 

10.  Serious Threats to Health or Safety.   Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.  Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. 

 

11.  Military.  Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 

 

12.  National Security and Intelligence Activities.  Our practice may disclose your PHI to federal officials for national security and intelligence activities authorized by law.  We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

 

13.  Inmates.  Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.  Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals. 

 

14.  Workers’ Compensation.  Our practice may release your PHI for workers’ compensation and similar programs, but only as authorized by, and to the extent necessary to comply with, laws relating to workers' compensation and similar programs that provide benefits for work-related injuries or illness.

 

15.  Government Audits. We are required to disclose your protected health information to the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA privacy rule.

 

E.     OTHER DISCLOSURES:

 

If a use or disclosure is not otherwise permitted under the law, we may still use or disclose your PHI under the following circumstances:

 

1.      Authorizations. Other uses and disclosures that are not identified by this notice or permitted by applicable law will only be made with your written authorization.  For example, in general and subject to specific conditions, we will not use or disclose your psychiatric notes; we will not use or disclose your PHI for marketing; and we will not sell your PHI unless you give us a written authorization. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing.  After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.  Please note, we are required to retain records of your care. 

 

2.      Personal Representatives.  We will disclose your PHI to individuals authorized by you, or to an individual designated as your personal representative, attorney-in-fact, etc. so long as you provide us with a written authorization and any supporting documents (e.g., power of attorney).  Note: under the HIPAA rules, the practice does not have to disclose information to a personal representative if we have a reasonable belief that:

 

·         You have been, or may be, subject to domestic violence, abuse or neglect by such person; or

·         Treating such person as your personal representative could endanger you; and

·         In the exercise of professional judgment, it is not in your best interest to treat the person as your personal representatives. 

 

F.     YOUR RIGHTS REGARDING YOUR PHI:

 

     You have the following rights regarding the PHI that we maintain about you: 

 

1.      Right to Request Confidential Communications.  You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location.  For instance, you may ask that we contact you at home, rather than work.  In order to request a type of confidential communication, you must make a written request to [Privacy Officer, 205 West R.D. Mize Road, Suite 304, Blue Springs, MO 64014]  specifying the requested method of contact, or the location where you wish to be contacted.  Our practice will accommodate reasonable requests.  You do not need to give a reason for your request.

 

2.      Right to Request Restrictions.  You have the right to request a restriction in our use or disclosure of you PHI for treatment, payment or health care operations.  Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends.  Except as provided in the paragraph below, we are not required to agree to your request.  However, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.  We will honor the restriction until you revoke it or we notify you. 

 

We will comply with any restriction request if: (1) except as otherwise required by law, the disclosure is for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and (2) the PHI pertains solely to a health care item or service to which the health care provider involved has been paid in full by you or another person. 

 

In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to [Privacy Officer, 205 West R.D. Mize Road, Suite 304, Blue Springs, MO 64014].  Your request must describe in a clear and concise fashion:

 

(a)    the information you wish restricted;

(b)   whether you are requesting to limit our practice’s use, disclosure or both; and

(c)    to whom you want the limits to apply.

 

  1. Right to Inspect and Copy.  You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes.  You must submit your request in writing to [Privacy Officer, 205 West R.D. Mize Road, Suite 304, Blue Springs, MO 64014] in order to inspect and/or obtain a copy of your PHI.  Our practice may charge a fee for the costs of copying, mailing, labor and supplies 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. 

 

  1. Right to Request an Amendment.  You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice.  To request an amendment, your request must be made in writing and submitted to [Privacy Officer, 205 West R.D. Mize Road, Suite 304, Blue Springs, MO 64014].  You must provide us with a reason that supports your request for amendment.  Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing.  Also, we may deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information. 

 

  1. Right to be Notified of a Breach.  You have the right to be notified in the event that we (or a business associate) discover a breach of unsecured PHI.

 

  1. Right to an Accounting of Disclosures.  You have the right to request an "accounting of disclosures."  An accounting of disclosures is a list of certain disclosures our practice has made of your PHI.  An accounting of disclosures will not include: (1) disclosures for purposes of treatment, payment or health care operations; (2) disclosures made to you; (3) disclosures pursuant to your authorization; (4) disclosures made to friends or family in your presence or because of an emergency; (5) disclosures made for national security purposes; and (6) disclosures incidental to otherwise permissible disclosures.

 

In order to obtain an accounting of disclosures, you must submit your request in writing to [Privacy Officer, 205 West R.D. Mize Road, Suite 304, Blue Springs, MO 64014].  All requests for an accounting of disclosures must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (for example, paper or electronic).  The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period.  Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. 

 

6.  Right to a Paper Copy of This Notice.  You are entitled to receive a paper copy of our Notice.  You may ask us to give you a copy of this Notice at any time.  To obtain a paper copy of this Notice, contact [Privacy Officer, (816) 228-4770].

 

7.  Right to File a Complaint.  If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Office of Civil Rights of the United States Department of Health and Human Services. To file a complaint with our practice, contact [Privacy Officer, (816) 228-4770].  All complaints must be submitted in writing. You will not be penalized for filing a complaint with the Office of Civil Rights or with us.

 

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