Shoreline Orthopedics & Sports MedicineNotice
Explain how, when and why we use and disclose protected health information
Abide by the terms of this Notice, as currently in effect;
Notify you if we are unable to agree to a requested restriction on how
your protected health information is used or disclosed;
Accommodate reasonable requests that you make to communicate health information
by alternative means or at alternative locations; and
Obtain your written authorization to use or disclose your protected health
information for reasons other than those listed below and permitted by law.
We know that your protected health information is personal. We are
committed to protecting your information. So as to provide you with
good care and to insure that we follow all legal requirements, we document
(in a medical record) the care and services that we provide to you. This
Notice applies to those records.
CHANGES TO THIS NOTICE
We reserve the right to change the terms of this Notice of Privacy Practices
and to make the new provisions effective for all protected health information
we already have about you, as well as any protected health information we
create or receive in the future. If we make any changes, we will:
Post the revised Notice in our office(s), which will contain the new effective
Make copies of the revised Notice available to you upon request, (either
at our offices or through the contact person listed in this notice.
WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU TO
PROVIDE TREATMENT TO YOU, TO OBTAIN PAYMENT FOR SERVICES RENDERED TO YOU,
AND FOR HEALTHCARE OPERATIONS.
We may use and disclose your protected health information for purposes of
healthcare treatment, payment and healthcare operations as described below.
We may use and disclose your protected health information to provide you
with medical treatment and services and to coordinate or manage your healthcare
and related services.
We may use and disclose your protected health information to doctors and
nurses, as well as lab technicians, dieticians, physical therapists or other
parties involved in your care, both within our organization and with other
health care providers involved in your care. We may disclose information
to people outside our practice who may be involved in your care, such as your
family members, clergy or others who participate in your care. All information
is recorded in your medical record, which is necessary for health care providers
to determine what treatment you should receive. Healthcare providers
will also record actions taken by them in the course of your treatment and
note your reactions. We may also disclose your protected health information
to providers or facilities who may be involved in your care after you leave
our facility or our care.
Examples of how we will disclose information for treatment may include sharing
information about you with:
Your primary care physician or family physician;
Ambulatory care centers,
We may use and disclose your protected health information so that we can
bill and receive payment for the treatment and services you receive from us. For
billing and payment purposes, we may disclose your protected health information
to an insurance company or managed care company, Medicare, Medicaid, or any
other third party payer. The information on the bill may contain information
that identifies your diagnosis, treatment and supplies used in the course
of treatment. We may inform an insurance company about treatment that
we intend to provide to you so that we can obtain the appropriate approvals
and/or to confirm coverage for your treatment.
Examples of how we will disclose information for payment include:
We may contact your health plan to confirm you coverage,
We may contact your health plan for pre-certification of a service,
We may contact any other organizations who provided you with medical services
to obtain payment information from them,
We may provide information to any other healthcare provider who requests information
necessary for them to collect payment,
We may share information with other
billing departments of other providers and healthcare entities,
share information with agents of health plans, (third party administrators)
who are involved in the payment of a claim.
We may share information
with consumer reporting agencies (credit breaus).
We may use or disclose
your protected health information to train
Students, residents, other
health care providers or non-health care providers, (such as billing
We may use or disclose protected health information to organizations
that assess the quality of care we provide to our patients, (such as
government agencies or accrediting bodies);
We may use and disclose protected
health information to organizations that evaluate, certify or license
health care providers, staff or facilities in a particular specialty;
may use and disclose protected health information to assist others who
may be reviewing our activities such as accountants, lawyers, consultants,
risk managers, and others who assist us in complying with state and federal
We may use and disclose protected health information in the process
of selling our business or merging with other health care entities, or
giving control to someone else;
We may use and disclose protected health
information in the process of reviewing for health care fraud and abuse
detection and compliance.
We may use and disclose protected health information
when we develop internal protocols;
In the process of using your protected health information
in the course of treatment, payment and health care operations,
we may make incidental disclosure. We will make reasonable steps to
limit incidental disclosures.
Practice-specific example: We may disclose information as it relates
to health care operations when we:
Leave messages on your answering machine.
Leave messages at your place of employment.
Send appointment reminder postcards.
Call to remind you of an appointment.
Call you by name when you are in our practice.
Share office space with another health care provider.
OTHER USES AND DISCLOSURES WE MAY MAKE WITHOUT
YOUR WRITTEN AUTHORIZATION:
Under the Health Insurance Portability and Accountability Act Privacy Regulations,
we may use and disclose your protected health information in which you do
not have to give authorization or otherwise have an opportunity to agree or
“Use” refers to our internal utilization of your protected health
information. Specifically, “use” under the privacy regulations
means: “…with respect to individually identifiable health information,
the sharing, employment, application, utilization, examination, or analysis
or such information within an entity that maintains such information.” Disclosure
refers to the provision of information by us to parties outside of our organization. Specifically,
disclosure means: “…the release, transfer, provision of
access to our divulging in any other manner, or information outside of the
entity holding the information.” We may make the following uses
and disclosures of your protected health information without obtaining
a written authorization from you in situations such as:
Those Required by Law:
We may disclose your protected health information when required to do so
by law. For example, when federal, state or local law or other
judicial or administrative proceeding requires that we disclose information
Public Health Risk:
We may disclose your protected health information for public health activities. For
example, we may disclose protected health information about you if you have
been exposed to a communicable disease or may otherwise be at risk of spreading
a disease. Other examples may include reports about injuries or disability,
reports or births and deaths, reports of child abuse and/or neglect, and reports
regarding recall of products.
Our Facility Directory:
Unless you object, we may use and disclose certain limited
information about you in our directory , (or on our “sign-in sheet),
while you are in our practice. This information may include your name
and your location within our practice, (such as a department). Our directory
will not include specific medical information about you. We may disclose
directory information to people who ask for you by name.
Unless you object, we may disclose protected
health information about you to a family member, relative, close personal
friend, caregiver, neighbor or other person(s) you identify, including clergy,
who are involved in your care. These disclosures are limited to information
relevant to the person’s
involvement in your care, or in payment for your care.
Unless you object, we
may disclose protected health information about you to a public or private
agency, (like the American Red Cross) for disaster relief purposes. Even
if you object, we may still share information about you, if necessary for
the emergency circumstances.
Reporting Victims of Abuse, Neglect or Domestic Violence:
When authorized by law, or if you agree to the report, and if we believe
that you have been a victim of abuse, neglect or domestic violence, we may
use and disclose your protected health information to notify a government
Health Oversight Activities:
When authorized by law, we may disclose your protected health in-formation
to a health oversight agency for activities. A health oversight
agency is a state or federal agency that oversees the health care system. Some
of the activities may include, for example, audits, investigations, inspections
Judicial and Administrative Proceedings:
We may disclose your protected health information in response to a law suit,
dispute, court or administrative order. We also may disclose protected
health information in response to a subpoena, discovery request, or other
lawful process by another party involved in the action. We
will make a reasonable effort to inform you about the request.
We may disclose your protected health information for certain law enforcement
purposes, including, but not limited to:
Reporting certain types of wounds and/or other physical injuries (i.e.
Reports required by law;
Reporting emergencies or suspicious deaths;
Complying with a court order,
warrant, subpoena, or other legal process;
Identifying or locating a suspect
or missing person, material witness or fugitive;
Answering certain requests
for information concerning crimes, about the victims of crimes;
and/or answering requests about a death we believe may be the result of
Reporting criminal conduct that took place on our premises; and
situations to report a crime, the location of the crime or victim or the
identity, description and/or location of a person involved in the crime.
Coroners, Medical Examiners, Funeral Directors, Organ/Tissue
Donation Organizations:We may release your
protected health information to a coroner, medical examiner, and funeral
you are an organ donor, we may release your protected health information
to an organization involved in the donation of cadaveric organs and
tissue to enable them to carry out their lawful duties. We can
release information about deceased patients to funeral directors as
necessary in allowing them to carry out their duties. We may
disclose protected health information about you to a coroner or medical
examiner for the purposes of identifying you should die.
some situations, your protected health information may be used for research
purposes if an institutional review board has approved the research. The
institutional review board must have established procedures to insure that
your protected health information remains confidential.
Avert a Serious Threat to Health or Safety:
may use or disclose your protected health information to someone able
to help lessen or prevent the threatened harm when necessary to prevent
a serious threat to your health or safety or the health or safety of
the public or another person. The disclosure would only be to a person
or entity that would be able to help prevent the threat.
Military and Veterans:
If you are a member of the armed forces, we may use and disclose your protected
health information as required by military command authorities. We may
also release medical information about you if you are a member of a foreign
military, as required by the appropriate foreign military authority.National Security and Intelligence Activities Protective Services
For the President and Others:
We may disclosed protected health information to authorized federal officials
conducting national security, counterintelligence and intelligence activities
authorized by law.
Services for the President and Others:
We may disclose your protected health information to authorized federal
officials as needed, to provide protection to the President of the United
States, other persons, or foreign heads of states, or to conduct certain special
you are an inmate of a correctional institution or under the custody of
a law enforcement official, we may disclose your protected health in formation
to the correctional institution, or official, for certain purposes. This
type of disclosure is necessary for the following reasons:
To insure that the correctional institution will provide you withhealthcare;
protect your own health and safety;
To protect the health and safety of
For the safety and security of the correctional institution.
We may use or disclose your protected health information to comply with laws
and regulations relating to workers’ compensation or similar programs
established by law that provide benefits for work-related injuries and/or
We may use or disclose protected health information to remind you about:
appointments in our organization.
appointments that we have scheduled for you with other health care organizations.
Treatment Alternatives and Health-Related Benefits and Services:
may use or disclose your protected health information to inform you about
treatment alternatives and health-related benefits and services that may
be of interest to you. This may include telling you about:
other health care providers
ANY OTHER USE OR DISCLOSURE OF YOUR PROTECTED HEALTH
INFORMATION REQUIRES YOUR WRITTEN AUTHORIZATION
Under any circumstances other than those listed above, we will request that
you provide us with a written authorization before we use and disclose your
protected health information to anyone.
If you sign an authorization allowing us to disclose protected health information
about you in a specific situation, you can later revoke (cancel) your authorization
If you cancel your authorization in writing, we will not disclose your protected
health information about you after we receive your cancellation,
except for disclosures, which were already being processed or made before
we received your cancellation.
YOUR RIGHTS REGARDING YOUR PROTTECTED HEALTH INFORMATION:
You have the following rights regarding your protected health information
that we maintain:
The Right to Access Your Personal Protected Health Information:
Upon written request, you have the right to inspect and obtain a copy of
your medical/protected health information except under certain limited circumstances. Under
state law, if we make a copy of your medical record, we will not charge you
more than is permitted by the current rate allowed by state law for copies. We
may also charge you a reasonable fee for x-rays, mailing and other supplies
related to this request. You should submit your written request to access
your health information to our Privacy Officer, who is listed in this Notice.
We may deny your request to inspect or receive copies in certain limited
circumstances. If you are denied access to your medical/protected health
information, in some cases you will have the right to request a review of
this denial. A licensed health care professional designated by us, and
who did not participate in the original decision to deny access, will perform
The Right To Request Restrictions:
You have the right to request that a restriction on the way we use or disclose
your protected health information for treatment, payment or health care operations. Additionally,
you can request that we limit the information we disclose about you to those
individuals involved in your care or the payment of your services, such as
a relative or friend. For example, you could request that we not use
or disclose information about a procedure you had performed by one of our
physicians. You should submit your written request to restrict your
health information to our Privacy Office, who is listed in this Notice. You
must tell us what information you want restricted., to whom you want the information
restricted, and whether you want to limit our use, disclosure or both.
However, we are not required to agree to such a restriction. If
we do agree to the restriction, we will honor that restriction except in the
event of an emergency and will only disclose the restricted information to
the extent necessary for your emergency treatment.
The Right to Request Confidential Communications:
You have the right to request that we communicate with you concerning your
health matters in a certain manner or at a certain location. For example,
you can request that we contact you only at a certain phone number, or a specific
You should submit your written request for Confidential Communications to
our Privacy Officer, who is listed in this Notice. You must tell us
how and where you want to be contacted.
We will accommodate your reasonable requests, but may deny the request if
you are unable to provide us with appropriate methods of contacting you.
The Right to Request an Amendment:
You have the right to request that we make amendments or modify your clinical,
billing and other protected health information for as long as the information
is kepy by us. Your request must be made in writing and must explain
your reasons for the requested amendment.
We may deny your request for amendment if the information:
was not created by us (unless you prove the creator of the information
is no longer available to amend the record);
is not part of the records maintained by us;
in our opinion, is accurate and complete;
is information to which you do not have a right of access.
If we deny your request for amendment, we will give you a written denial
notice, including the reasons for the denial and explain to you that you have
the right to submit a written statement disagreeing with the denial. Your
letter of disagreement will be attached to your medical record.
You should submit your written request for an amendment to our Privacy Officer,
who is listed in this Notice.
The Right to An Accounting of Disclosures:
You have the right to request an accounting, (a report), of certain disclosures
of your protected health information. You may ask for disclosures made
up to six years before your request, (but not including disclosures made prior
to April 14, 2003). This is a listing of disclosures made by us or by
others on our behalf. We are not required to include disclosures:
made for treatment;
made for billing or collection or payment for your treatment;
made directly to you, that you authorized, or those which are made to
individuals involved in your care;
allowed by law when the use or disclosure
related to certain government functions or in other law enforcement
custodial situations, and/or;
made in the process of our health care operations.
You must submit your request for an accounting of disclosures in writing
to the Privacy Officer, who is listed in this Notice. You must state
that time period for which you would like the accounting. The accounting
will include the disclosure date, the name, address, (if known) of the person
or entity that received the information, a brief description, of the information
disclosed; and a brief statement of the purpose of the disclosure. If
you request a listing of disclosures more than once within a 12-month period,
we will charge you a reasonable fee for the accounting. The first accounting,
within a 12-month period, is provided to you at no charge. We will inform
you of the costs involved in the event that you wish to withdraw your request.
The Right to a Paper Copy of This Notice:
You have the right to obtain a paper copy of this Notice, even if you have
agreed to receive this Notice electronically. You may request a copy
of this Notice at any time by contacting our office in writing or by phone.
DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE AND
For uses and disclosures of your protected health information related to
care for psychiatric conditions, substance abuse, or HIV-related information,
special conditions may apply. For example, we generally may not disclose
this specially protected information in response to a subpoena, warrant or
other legal process unless you sign a special authorization or if a court
orders the disclosure. A general release of your protected health information
will not be sufficient for purposes of disclosing psychiatric, substance abuse
or HIV-related information.
We will not disclose records relating to a diagnosis or treatment of your
mental condition between you and the psychiatrist without specific written
authorization or as required or permitted by law.
HIV-related information will not be disclosed, except under limited circumstances
set forth under state or federal law, without your specific written authorization.
3.Substance Abuse Treatment:
If you are treated in a substance abuse program, information which could
identify you as alcohol or drug-dependent will not be disclosed without your
specific authorization except for purposes of treatment or payment or when
specifically required or allowed under state or federal law.
If you believe that your privacy rights have been violated, you may file
a complaint in writing to us or with the government:
To file a complaint with the government, you may contact:
Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.,
Washington, D.C. 20201
To file a complaint with us, you should contact the contact person mentioned
on page one.
You will not be retaliated against for filing a complaint