Notice of Privacy Practices
Jason C. Cheung, MD, PS
Notice of Privacy Practices
Effective April 14, 2003
This Notice of Privacy Practices is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your individually identifiable health information.
Please review this notice carefully. If you have any questions about this Notice of Privacy Practices please speak to the receptionists at the front desk or call our office at anytime and we will connect you with our Privacy Officer to assist you with any questions or concerns. The content and information covered in our Notice of Privacy Practices (Notice) is divided into the following areas for your review.
General information about the Notice of Privacy Practices.
How we may use and disclose your protected health information.
Uses and disclosures of protected health information required by law and other special circumstances.
Your individual rights.
General information about the Notice of Privacy Practices.
Who does this notice apply to and what is our pledge regarding your medical information?
We understand that medical information about you and your health is personal. We are committed to protecting all medical information about you. We create a record of the care and services you receive at our practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to everyone who works for our practice including employees, contractors, and volunteers.
Why do we publish this Notice?
As medical professionals, we understand that information about you and your health is sensitive and personal. We are also required by law to maintain the privacy of information we gather and use about our patients, and provide them with notices of our legal duties and privacy practices with respect to their information. We are committed to the privacy of our patients’ information; however, in order to serve them we need to gather, keep and use records of this information. We sometimes need to share information with other parties. This Notice is intended to let you know how we may use and disclose your information. This Notice also informs you of the legal rights you have with respect to the information we hold about you. You have certain rights to review and copy our records of information about you. You may also request that we amend these records, and may ask us to account for certain disclosures we may have made of information about you. Our practice is required to retain and maintain records of the care given to you.
When is this Notice Effective?
We are required to comply with the terms of this Notice while it is in effect. We reserve the right to change the terms of this Notice, and make the new terms effective for all information to which this Notice applies. This Notice will be in effect immediately until the date we publish an amended Notice. If we do publish an amended Privacy Notice, we will notify you in one or more of the following ways: by sending you a copy at your last address shown in our records; by publishing the amended Privacy Notice in our offices; and/or by publishing it on our web site if we maintain one. You may request a copy of our most current Privacy Notice at any time.
Why do we ask you to sign a Consent Form?
We can only use or disclose information about you in very limited ways without your consent. However, we cannot provide treatment, and cannot conduct payment and certain necessary health care operations activities without using or in some cases disclosing your information. Since these are essential activities for us, we need you to give your written consent for these purposes. Because this is such important information, if you refuse to consent we may not be able to provide you care.
How we may use and disclose your health information.
We may, with your consent, use and disclose your health information inthe following ways:
We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to other doctors, nurses, technicians, or medical students who are involved in taking care of you in our practice. For example, your doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Departments internal or external to our practice also may need your medical information in order to coordinate different treatments you need such as prescriptions, lab work, and x-rays.
We may use and disclose medical information about you so that the treatment and services you receive at our practice may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your care received so your health plan will pay us or reimburse you for treatments provided to help keep you healthy. We may also tell your health plan about treatments you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
Health Care Operations –
We may use or disclose information about you for operational functions in connection with our practice. Examples of some activities might include practices involving quality improvement, audits of our management practices, training of students involved in health care, insurance underwriting, medical and legal reviews, and business planning or administration or our practice.
Appointment Reminders – (OPTIONAL)
Unless you object, our practice may use and disclose your information to contact you and remind you of an appointment. For example, we may mail you a postcard or call you on the phone to remind you of an appointment scheduled with our practice.
Treatment Options and Health-Related Benefits – (OPTIONAL)
Unless you object, our practice may use and disclose information about you to inform you of potential medical options or alternative treatments or other health-related benefits and services that may improve the health and quality of your life. For example, we may mail you information about a new medication option or Botox related facial therapy.
Release of information to family and friends – (OPTIONAL)
We may, unless you object, using our best discernment, disclose information to a family member, other relatives, close personal friends or any other person you identify having relevant involvement in your care or payment related to your care. For example, we may acknowledge to a spouse that you are in our office for an appointment, or we may disclose information to relative who is involved in helping you make decisions about a surgical procedure.
Disclosures by required by Law
Our practice will use and disclose your information when we are required to do so by Federal, State or Local Law.
Uses and disclosures of health information required by law and other special circumstances.
We are legally required to use or disclose protected health information about you without your consent to meet special reporting requirements, to facilitate continuity of care, or for public health and other purposes. Some examples include:
Public Health Risks –
We may disclose protected health information about you for public health activities. These activities generally include the following:
To prevent or control disease, injury or disability.
To report births and deaths.
To report child abuse or neglect.
To report reactions to medications or problems with products.
To notify people of recalls on the products they may be using.
To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only disclose this if you agree or when required by law.
Law enforcement –
Under applicable Federal and State laws, we may disclose your protected health information if we believe that its use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose your protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military and Veterans –
We may release protected health information about you as required by military command authorities for activities believed necessary to determine fitness for duty, eligibility for VA benefits, or to a foreign military authority if you are a member of that foreign military service.
National Security –
We may disclose your protected health information to authorized Federal officials for conducting national security and intelligence activities including protective services to the President or other officials or foreign heads of state, or to conduct special investigations.
Workers’ Compensation –
We may release protected health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Health Oversight –
We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure. These health oversight agencies might include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Lawsuits and Disputes –
If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court order or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety; (3) for the safety and security of the correctional institution.
Coroners, Medical Examiners and Funeral Directors –
We may release protected health information to a coroner or medical examiner, to identify a deceased person or determine the cause of death. If necessary we may also release protected health information in order for funeral directors to carry out their duties.
Organ and Tissue Donation –
If you are an organ donor, we may release your protected health information to organizations that handle organ, eye or tissue procurement or transplantation, including organ banks, as necessary to facilitate organ or tissue donation and transplantation.
We may disclose your protected health information to researchers when authorized by law or for example, if their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Your individual rights.
Right to Request Confidential Communications –
You may request that we communicate with you using alternative means or at an alternative location. We will not ask you the reason for your request. In order to request a specific type of communication, regarding the method and/or location you wish to be contacted, you must provide a written request to our practice. (Attached at the end of this Notice is the person and information to whom written requests are to be addressed.) We will accommodate reasonable requests, when possible.
Right to Request Restrictions –
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment and health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as family members or friends. 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. In order to request a restriction in our use or disclosure of your protected health information, you must provide a written request to our practice. Attached at the end of this Privacy Notice is the person and information to whom written requests are to be addressed. Your request must describe in a clear and concise fashion: (1) the information you wish to restrict, (2) whether you are requesting to limit our practice’s use, disclosure or both, and (3) to whom you want the limits to apply.
Right to Record Inspection and Copies –
You have the right to inspect and obtain a copy of the protected health information that may be used to make decisions about you. This includes your medical records and billing records, but does not include psychotherapy notes. To obtain a copy or inspect your protected health information, you must submit a request in writing to our practice. Attached at the end of this Privacy Notice is the person and information to whom written requests are to be addressed. 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, if this occurs, you may request a review of our denial. Another licensed health care professional chosen by the practice will review your request and the denial. The person conducting the review will not be the person who denied your initial request. We will inform you of the outcome.
Right to Amendments –
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 to our practice. Attached at the end of this Privacy Notice is the person and information to whom written requests are to be addressed. You must provide us with a reason that supports your request for the amendment. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment, (2) is not part of the medical information kept by this practice, (3) is not part of the information, which you would be permitted to inspect and copy, and (4) is accurate and complete.
Right to Accounting of Disclosures –
You have a right to request an “accounting of disclosures.” This is a list of certain non-routine disclosures we made of the medical information about you. The accounting of disclosures does not require us to list for example a doctor sharing information with the nurse, another doctor or the billing department. all requests for an accounting of disclosures must be made in writing to our practice. (Attached at the end of this Notice is the person and information to whom written requests are to be addressed.) The request must state a time period, which may not be longer than 6 (six) years and may not include dates before April 14, 2003. The first list you request within a 12 (twelve) month period is free of charge, but our practice may charge you for additional lists withing the same 12 (twelve) month period. We will notify you of the costs involved with additional requests and you may withdraw your request before you incur any costs.
Right to Authorize Other Uses and Disclosures –
Other uses and disclosures of medical information not covered by this Privacy Notice or the laws that apply to us will be made only with your written authorization/consent/permission. If you provide us with permission to use or disclose medical information about you, and subsequently desire to revoke that authorization you may do so at any time in writing to our practice. (Attached at the end of this Notice is the person and information to whom written requests are to be addressed.) If you revoke the authorization, we will no longer use or disclose medical information about you for the reasons described in your written authorization. Our practice will not be able to take back any disclosures we have already made with your permission.
Right to a Paper Copy of this Privacy Notice –
You have the right to be provided with a paper copy of this Privacy Notice from our practice. You may ask us to give you a copy of this Privacy Notice at any time. (Attached at the end of this Privacy Notice is the person who may provide you with a copy.) Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy.
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 Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. To file a complaint with our practice contact the HIPAA Compliance Coordinator listed at the end of this Privacy Notice. The Secretary of the Department of Health and Human Services requires that the complaint be in writing, either paper or electronically, that it names the practice involved and the acts or omissions believed to be in violation, and that this be filed within 180 days of when you knew the omission or act occurring. You will not be penalized for filing a complaint.
Changes to this Privacy Notice
We reserve the right to change this Privacy Notice. We reserve the right to make the revised or changed Privacy Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Privacy Notice in the practice the privacy Notice will contain the effective date on the first page under the title Notice of Privacy Practices.
Send written request to:
Dr Jason C. Cheung
Attn: HIPAA Compliance Coordinator
9800 Levin RD NW, Suite 208
Silverdale, WA 98383