Freeman Family Medicine
600 Club Lane
Conway, AR 72034-3624
ph 501-327-0110
HIPAA Agreement
NOTICE OF PRIVACY PRACTICES
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.
This notice provides you with information on the steps which Freeman Family Medicine (further referred to as the clinic) has taken to protect the privacy of your Protected Health Information (PHI). It also describes some of the privacy rights you have and how you exercise those rights. Please read this carefully. If you have any questions, you may ask to speak with our Privacy Official Rebekah Wilkins. She can answer any questions you have regarding this notice.
Your Protected Health Information is information that is created or received by this clinic (transmitted by electronic form or maintained in any medium) that identifies you or could reasonably identify you, and relates to your past, present, or future such as follows:
Physical or mental health or condition
Your healthcare treatment
The payment of your healthcare services
I. USES AND DISCLOSURES
A. The following are examples of some ways the clinic may use and disclose your Protected Health Information (PHI) based on your signing our clinic consent form
1.Treatment
To adequately provide for your healthcare needs, your PHI will be used and disclosed within the clinic by our clinic employees and independent contractors as necessary to treat, evaluate, and provide you with necessary healthcare services. This may also include the need for us to obtain PHI from your previous healthcare providers so that we may properly manage your care.
2. Payment
To receive payment for our services, the clinic will have to disclose certain PHI to your Health Plan or Insurer. This could require disclosure prior to treatment to obtain pre-certification from your Insurer to perform a procedure, or it could be a post treatment disclosure to obtain payment for the services provided. Your Insurer also has a right to demand access to your records to determine eligibility for making pre-existing condition determinations or for conducting quality control inspection. PHI may also be disclosed to comply with worker’s compensation laws and similar programs. The Clinic may also disclose limited PHI to consumer reporting agencies relating to collection of payments owed to the clinic.
3. Clinic Operations
To ensure the proper functioning of our clinic, it may be necessary from time to time that certain PHI be used and disclosed. For example, we may use a sign-in sheet at the front desk to keep track of which patients have arrived. We may call out your name when it’s time to come back to the exam room. Our employees and independent contractors may have to access our medical records for certain business operations. Our Clinic may allow high school, college, or medical school “shadow” students in the clinic, and they may be exposed to certain PHI.
4. Referrals
To effectively refer you to another physician, we will have to release certain PHI to that physician to assist that physician in your treatment and to make the necessary appointment.
5. Consultations
There may be occasions where the clinic may desire to consult another professional about your treatment to get a second opinion. In those situations, the clinic will always attempt to maintain your privacy to the maximum extent possible but recognize that it may not always be an option. Furthermore, the Conway Regional Health System makes available its records via electronic access, and Freeman Family Medicine is authorized to access those records for the purpose of carrying out treatment, payment or any other healthcare operations.
6. Business Associates
As part of our business operations, we have to enter into agreement with third parties to assist us. These third parties can be accountants, computer consultants, transcriptionists, etc. These third parties may have access to PHI. However, prior to any of our Business Associates having access to PHI, they will sign an agreement that requires them to follow HIPAA procedures to protect the privacy of your PHI.
B. The following are examples of some of the ways the clinic may use and disclose your PHI based on your opportunity to orally agree or object
1. Family Members of Individuals Involved in Your Care
This clinic may use and disclose PHI to your family members or other individuals who are involved in your care when the clinic believes it is necessary to provide your location, your general health condition, or in the case of your death. An example might be if you needed a ride home, we may contact a relative to provide you with a ride. You may inform our Privacy Official in writing if you choose to object to this use or disclosure.
2. Faculty Directories
We may use PHI to maintain a listing of the name, location, general condition, and religious affiliation of individuals in our facilities and disclose it to religious personnel and to others who specifically request information by identifying the individual by name. You may inform our Privacy Official in writing if you choose to object to this use or disclosure.
3. Release of Immunization Records to Schools
The clinic may release immunization records directly to schools with only an oral authorization from a parent or person acting in place of the parent.
C. The following are examples of some ways the clinic may use and disclose your PHI without your consent, authorization, or opportunity to agree or object
1.Legal Obligations
This clinic will use and disclose PHI when legally required. If this situation occurs, we will notify you and we will limit the PHI to the minimum necessary to comply with the law. Some examples are as follows: court orders, subpoenas, reporting suspected abuse or neglect, reporting adverse results to the Food and Drug Administration, reporting exposures to communicable disease, certain criminal activity, and military activity.
2. Inmates
If you are an inmate, this clinic may use or disclose PHI to the facility and correctional officers when appropriate.
3. Emergencies
In an emergency treatment situation, our clinic may disclose PHI to the facility and correctional officers when appropriate.
4. Communication Barrier
If there is a substantial communication barrier, this clinic may use or disclose PHI for treatment, payment, or healthcare operations when circumstances would infer consent.
D. The following are examples of some of the ways the clinic may use and disclose your PHI based on your signing our clinic Authorization Form
Other uses and disclosures of your PHI that do not fit into one of the above categories and upon your signing a clinic Specific Authorization Form. An example of when this may be necessary is if you would want our clinic to release your medical records to your employer. You would need to come in and complete a Specific Authorization for us to disclose your PHI to your employer, unless your employer is your health insurer. If your employer is your private health insurer, then they would have access to your medical records through your general consent form. You have the right to revoke any authorization. However, the revocation will not be effective to the extent the clinic has relied on it.
E. Certain disclosures cannot be made without your specific authorization
1. Psychotherapy Notes
Most uses and disclosures or psychotherapy notes are prohibited unless you specifically authorize their release.
2. Sale of PHI
The sale of PHI occurs when the clinic makes a disclosure of PHI and directly or indirectly receives remuneration from the recipient in exchange for the PHI.
3. Use of PHI for Marketing
If the clinic were to use PHI for marketing purposes.
Additional disclosures include
F. Use of PHI for Fundraising
PHI may be used for fundraising purposes. You have the right to opt out of receiving such communications by contacting the Privacy Official.
2. Disclosure of PHI to a Plan Sponsor
PHI may be disclosed to a plan sponsor, in cases of a group health plan, health insurance, or HMO.
3. Disclosure of PHI for Underwriting Purposes
PHI may be disclosed for underwriting purposes, in which case PHI that contains genetic information will be excluded from such disclosure.
II. RIGHTS
A. Right to Request a Restriction of Uses and Disclosures
You have the right to notify our Privacy Official in writing that you request a restriction on our use and disclosure of your PHI. Our clinic does not have to grant your request, and we can condition treatment on your willingness to consent to our uses and disclosures of your PHI. We will notify you in writing whether we will grant or deny your request. If your request is granted, we may choose at a later date to deny the continuing of the restriction. If so, we will notify you in writing of that decision.
B. Right to Confidential Communications
You have the right, by making a written request, to request that all our communications with you concerning your PHI be confidential. Your request must tell us how or where you wish to be contacted. We are required to accommodate only reasonable requests. We cannot ask you the reason for such a request.
C. Right to Inspect and Copy
You have the right, by making a written request, to inspect and copy your PHI. There are a few exceptions to this rule. We must approve or deny your request within 30 days, although a one-time 30-day extension is allowed. In case of a denial, we will provide you with an explanation of the denial.
We will charge a reasonable fee for copying, preparation, and postage (if mailed to you), which must be prepaid. If the clinic has electronic medical records, you also have the right to request that your PHI be provided to you in an electronic format.
D. Right to Amend
You have the right, by making a written request, to request that we amend your PHI that we created. If you make such a written request, we will act on your request and respond in writing within 60 days. Should your request be denied, an explanation will be provided. You will have the right to appeal any denial to amend PHI.
E. Right to Receive an Accounting
You have the right, by making a written request, to request that we provide you with an accounting of our disclosures for your PHI. The accounting will be provided within 60 days of the request. Standard disclosures are not included in the accounting. Examples of standard disclosures would be disclosures to you, for treatment, payment, and healthcare operations. The first accounting in a 12-month period is free. Any subsequent request for an accounting in the same 12-month period will result in a reasonable, cost-based fee.
F. Right to Receive Copy of Notice
You have a right to receive a paper copy of our Notice of Privacy Practices. You may pick one up at the front desk.
G. Right to File a Complaint
The law requires us to comply with HIPAA and our Notice of Privacy Practices. If you feel we are not in compliance, you have the right to file an anonymous complaint with our office. You can also file a complaint by notifying our Privacy Official in writing. We will not retaliate in any manner due to a complaint, as we value your opinion. You also have a right to file a complaint with the Secretary of the Department of Health and Human Services, who is charged with enforcement of this regulation.
H. Right to Restrict Release of PHI for Certain Services
You have the right to restrict the disclosure of information regarding services, treatment or other items you have paid for in full or on an out-of-pocket basis. This information can be released only upon your written authorization.
I.The Right to Be Notified in Case of a Breach of PHI
You have the right to be notified of any breach of your unsecured PHI.
DISCLOSURE STATEMENTS:
A. This clinic intends to use and disclose Protected Health Information in the additional following ways on which treatment is conditioned:
1. To have you sign in on a sign in sheet
2. To allow our staff to call out your name when it is time for you to come back for an exam, treatment, or consultation
3. To send out reminders of appointments
4. To provide alternative treatment information
5. To leave messages on voicemail systems with appointment reminders
6. To contact you at the phone numbers you provide and leave messages to reschedule appointments and leave lab results
B. The law requires this clinic to have privacy protection for PHI and to give notice of its legal responsibilities to individuals
C. This clinic has to follow the terms and conditions contained in its Notice of Privacy Practices
D. This clinic retains the right to make retroactive changes to its Notice of Privacy Practices. This means that if the clinic changes its Notice of Privacy Practices, and thus changes its Privacy Practices and Procedures, it can and will apply those changes to the PHI it received, obtained and created prior to those changes if it chooses and states so in the Notice.
E. Any individual who would like a copy of any revised Notices of Privacy Practices shall submit such a request in writing to the Privacy Official whose name is listed on the first page of this Notice.