NOTICE OF PRIVACY PRACTICES

EFFECTIVE 10/01/2013

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.

As part of the federal Health Insurance Portability and Accountability Act of 1996, known as HIPAA, the clinic has created this Notice of Privacy Practices (Notice). This Notice describes the clinic’s privacy practices and the rights you, the individual, PRShave as they relate to the privacy of your Protected Health Information (PHI). Your PHI is information about you, or that could be used to identify you, as it relates to your past and present physical and mental health care services, payment for such services or you or your family members’ genetic information. The HIPAA regulations require that the clinic protect the privacy of your PHI that the clinic has received or created.

This clinic will abide by the terms presented within this Notice. For any uses or disclosures that are not listed below, the clinic will obtain a written authorization from you for that use or disclosure, which you will have the right to revoke at any time, as explained in more detail below. The clinic reserves the right to change its’ privacy practices and this Notice. Revisions to the Notice will be available in the clinic and provided to you in a paper format, upon your request.

HOW THE CLINIC MAY USE AND DISCLOSE YOUR PHI

The following is an accounting of the ways the clinic is permitted, by law, to use and disclose your PHI.

Uses and disclosures of PHI for Treatment: We will use the PHI we receive from you to provide medical treatment and coordinate or manage your health care.

Uses and disclosures of PHI for Payment: The clinic will disclose your PHI to your group health plan.

Uses and disclosures of PHI for Health Care Operations: The clinic may use the minimum necessary amount of your PHI to conduct quality assessments, improvement activities, and evaluate the clinic workforce.

The following is an accounting of additional ways in which the clinic is permitted or required to use or disclose PHI about you without your written authorization. All uses and disclosures will be to the minimum necessary amount of your PHI. Many of these uses and disclosures will never be made by the clinic; however, we are required by law to notify you of them as a health care provider.

Uses and disclosures as required by law: The clinic is required to use or disclose PHI about you as required and as limited by law.

Uses and disclosure for Public Health Activities: The clinic may use or disclose PHI about you to a public health authority that is authorized by law to collect for the purpose of preventing or controlling disease, injury, or disability. This includes the FDA so that it may monitor any adverse effects of drugs, foods, nutritional supplements and other products as required by law.

Uses and disclosure about victims of abuse, neglect or domestic violence: The clinic may use or disclose PHI about you to a government authority if it is reasonably believed you are a victim of abuse, neglect or domestic violence.

Uses and disclosures for health oversight activities: The clinic may use or disclose PHI about you to a health oversight agency for oversight activities which may include audits, investigations, inspections as necessary for licensure, compliance with civil laws, or other activities the health oversight agency is authorized by law to conduct.

Disclosures for judicial and administrative proceedings: The clinic may disclose PHI about you in the course of any judicial or administrative proceedings, provided that proper documentation is presented to the clinic.

Disclosures for law enforcement purposes: The clinic may disclose PHI about you to law enforcement officials for authorized purposes as required by law or in response to a court order or subpoena.

Uses and disclosures about the deceased: The clinic may disclose PHI about a deceased, or prior to, and in reasonable anticipation of an individual’s death, to coroners, medical examiners, and funeral directors.

Uses and disclosures for cadaveric organ, eye or tissue donation purposes: The clinic may use and disclose PHI for the purpose of procurement, banking, or transplantation of cadaveric organs, eyes, or tissues for donation purposes.

Uses and disclosures for research purposes: The clinic may use and disclose PHI about you for research purposes with a valid waiver of authorization approved by an institutional review board or a privacy board. Otherwise, the clinic will request a signed authorization by the individual for all other research purposes.

Uses and disclosures to avert a serious threat to health or safety: The clinic may use or disclose PHI about you, if it believes in good faith, and is consistent with any applicable law and standards of ethical conduct, to avert a serious threat to health or safety.

Uses and disclosures for specialized government functions: The clinic may use or disclose PHI about you for specialized government functions including; military and veteran’s activities, national security and intelligence, protective services, department of state functions, and correctional institutions and law enforcement custodial situations.

Disclosure for workers’ compensation: The clinic may disclose PHI about you as authorized by and to the extent necessary to comply with workers’ compensation laws or programs established by law.

Disclosures for disaster relief purposes: The clinic may disclose PHI about you as authorized by law to a public or private entity to assist in disaster relief efforts.

Disclosures to business associates: The clinic may disclose PHI about you to the clinic’s business associates for services that they may provide to or for the clinic to assist the clinic to provide quality health care. To ensure the privacy of your PHI, we require all business associates to apply appropriate safeguards to any PHI they receive or create.

OTHER USES AND DISCLOSURES

The clinic may contact you for the following purposes:

Appointment reminders: The clinic may contact you to remind you of your appointment for treatment or medical care at the clinic.

Information about treatment alternatives: The clinic may contact you to notify you of alternative treatments and/or products.

Health related benefits or services: The clinic may use your PHI to notify you of benefits and services the clinic provides.

Individuals Involved In Your Care: Unless you object, the clinic may disclose to a family member, other relative, or a close personal friend, or any other person you identify, PHI directly relevant to that person’s involvement with your care. The clinic will also disclose PHI to an individual if it can reasonably infer from the circumstances, based on the exercise of professional judgment that you do not object to the disclosure.

Electronic Medical Record (EMR): The EMR helps physicians, specialists and hospitals know a patient’s entire health history, drugs that have been prescribed and test results. To improve overall quality, safety and cost of care, the clinic may disclose information held in the EMR to other health care providers or Business Associates of the clinic.

FOR ALL OTHER USES AND DISCLOSURES

The clinic will obtain a written authorization from you for all other uses and disclosures of PHI, and the clinic will only use or disclose pursuant to such an authorization. The clinic is prohibited from selling your PHI. In addition, you may revoke such an authorization in writing at any time. To revoke a previously authorized use or disclosure, please contact HIPAA Privacy Officer to obtain a Request for Restriction of Uses and Disclosures.

YOUR HEALTH INFORMATION RIGHTS

The following are a list of your rights with respect to your PHI.

Request restrictions on certain uses and disclosures of your PHI: You have the right to request additional restrictions of the clinic’s uses and disclosures of your PHI; however, the clinic is not required to accommodate a request. If you wish to request additional restrictions, please obtain the form, Request for Restriction of Uses & Disclosures, from the clinic and return the completed form to the clinic or return to the HIPAA Privacy Officer.

The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the clinic communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the clinic to have an accurate address and home phone number in case of emergencies. The clinic will consider all reasonable requests. If you wish to request a change in your communicating address and/or phone number, please obtain a form, Request for Alternative Arrangements for Confidential Communication, from the clinic and return the completed form to the clinic or return to the HIPAA Privacy Officer.

The right to inspect and/or obtain a copy your PHI: You have the right to request access and/or obtain a copy (paper or electronic) of your PHI that is contained in the clinic for the duration the clinic maintains PHI about you. If you wish to inspect or obtain a copy of your PHI, please obtain a form, Request for Access to Records, from the clinic and return the completed form to the clinic or return to the HIPAA Privacy Officer. There may be a reasonable cost-based charge for providing access to PHI. You will be notified in advance of incurring such charges, if any.

The right to amend your PHI: You have the right to request an amendment of the PHI the clinic maintains about you, if you feel that the PHI the clinic has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we may deny your request for amendment. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who was not involved in the initial review. You may also ask the Secretary, United States Department of Health and Human Services (“HHS”), or their appropriate designee, to review such a denial. If you wish to amend your PHI files, please obtain a form, Request for Amendment to PHI, from the clinic and return the completed form to the clinic or return to the HIPAA Privacy Officer.

The right to receive an accounting of disclosures of your PHI: You have the right to receive an accounting of certain disclosures of your PHI made by the clinic. If you wish to receive an accounting of disclosures of your PHI, please obtain a form, Request for Accounting of Disclosures, from the clinic and return the completed form to the clinic or return to the HIPAA Privacy Officer. You should be aware; however, that such an accounting excludes uses and disclosures made for treatment, payment, or health care operations purposes.

The right to be notified of a Breach of your unsecured PHI: A “breach” is defined as the “unauthorized acquisition, access, use or disclosure of PHI in a manner which compromises the security or privacy of such information” and which poses “a significant risk of financial, reputational, or other harm to the individual.” If the clinic determines that a probability exists that your PHI may have been compromised, you will receive a notification by first-class mail regarding the breach at least sixty (60) days after the breach was discovered.

The right to receive additional copies of the Clinic’s Notice of Privacy Practices: You have the right to receive additional paper copies of this Notice, upon request, even if you initially agreed to receive the Notice electronically. If you wish to receive a paper copy of this request, please ask a clinic workforce member and they will provide you with a copy.

REVISIONS TO THE NOTICE OF PRIVACY PRACTICES

The clinic reserves the right to change and/or revise this Notice and make the new revised version applicable to all PHI received prior to its effective date. The revised Notice will be available, upon request, to all individuals. The clinic will also post the revised version of the Notice in the clinic.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the clinic and/or to the Secretary of HHS, or his designee. If you wish to file a complaint with the clinic, please contact the HIPAA Privacy Officer. If you wish to file a complaint with the Secretary, please write to:

The U.S. Department of Health and Human Services
Office of the Inspector General
200 Independence Ave, S.W.
Washington, D.C. 20201

The clinic will not take any adverse action against you as a result of your filing of a complaint.

CONTACT INFORMATION

If you have any questions on the clinic’s privacy practices or for clarification on anything contained within the Notice, please contact:

miCare LLC
STACEY L. LOUCKS
HIPAA PRIVACY OFFICER
2075 OVERLAND AVENUE
BILLINGS, MT 59102
(406) 245-3575, EXT. 1175
(800) 777-3575