Notice of Privacy Practices

292 S 1470 E
(435) 628-9200

As required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Updated July 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.

I. Southwest Internal Medicine’s Privacy Practices
Southwest Internal Medicine desires to protect your privacy and the confidentiality of your medical and health information. This Notice describes the privacy practices of Southwest Internal Medicine and its employees.

II. Our Privacy Responsibilities
Southwest Internal Medicine maintains the privacy of medical and health information about you as required by law. The law refers to your medical and health information as “Protected Health Information” (PHI). One requirement of the law is to give you this Notice to describe the way we may use and share your Protected Health Information.

III. Uses and Disclosures of Protected Health Information Permitted by Law
The law permits us to use your Protected Health Information for treating you, billing for services, and for health care operations, all of which are explained below. Some health records, including confidential communications with a mental health professional, substance abuse treatment records, and genetic tests results, may have additional restrictions for use and disclosure under state and federal laws. Your Protected Health Information may be used and disclosed only for the following purposes:

1. Treatment. To provide treatment and other services to you-for example, to diagnose and treat your injury or illness, to send you appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you;

2. Payment. To obtain payment for services provided to you-for example, disclosures to claim and obtain payment from your health insurer or Medicare;

3. Health Care Operations. To conduct health care operations-for example, to evaluate the quality of treatment and services provided by our physicians, nurses, and other health care workers;

4. Individuals Involved in Your Care or Payment for Your Care. To a family member, a close personal friend, or any other person identified by you if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonable infer that you do not object to the disclosure;

5. Health Care Communications. To identify health-related services and products that may be beneficial to you and then contact you about the services and products;

6. Public Health Activities. To report: (a) health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability; (b) child, adult, or elder abuse and neglect, domestic violence, to public health authorities, government authorities, or other services authorized by law to receive such reports; (c) information about products under the jurisdiction of the U.S. Food and Drug Administration; (d) communicable disease risks to a person who may have been exposed or be at risk to contracting or spreading a disease or condition; (e) information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; and (f) submit to Medicaid eligibility database and the Children’s Health Insurance Program eligibility database;

7. Health Oversight Activities. To a health oversight agency that oversees the health care system and ensure compliance with the rules of government health programs such as Medicare and Medicaid;

8. Judicial and Administrative Proceedings. In the course of a judicial or administrative proceeding in response to legal order or other lawful process;

9. Threat to Health and Safety. To reduce or prevent a serious threat to public health and safety.

10. Law Enforcement Officials; Specialized Government Functions. To: (a) the police or other law enforcement officials as required by law or in compliance with a court order; (b) Military authorities the personal and health information of Armed Forces personnel under certain circumstances; or (c) authorized federal officials personal and health information required for lawful intelligence, counterintelligence, and other national security activities;

11. Decedents. To a coroner, medical examiner, or funeral director as authorized by law;

12. Organ and Tissue procurement. To organizations that facilitate organ, eye, or tissue procurement, banking, or transplantation;

13. Research. To an authorized researcher if our Institutional Review Board or Privacy Board approves release under very strict government guidelines; and

14. Worker’s Compensation. To comply with worker’s compensation laws.

IV. Uses and Disclosures With Your Authorization
Southwest Internal Medicine cannot use your Protected Health Information for anything other than the reasons mentioned above, without your signed “Authorization.” An “Authorization” is a written document signed by you that permits Southwest Internal Medicine to use your protected Health Information for a specific purpose. You may revoke your authorization by delivering a written revocation statement to the Privacy Officer identified below. If you revoke your Authorization, Southwest Internal Medicine will no longer use or disclose your Protected Health Information as permitted by your Authorization. Of course, your revocation of Authorization will not reverse the use or disclosure of your Protected Health Information while your Authorization was in effect.

V. Your Individual Rights

1. For Further Information; Complaints. Please contact us (see address and telephone number in Section VI.3 below) if you desire further information about your privacy rights, are concerned that your privacy rights have been violated, or disagree with a decision that we made about access to Protected Health Information. You may also file written complaints with the director of the Office of Civil Rights of the U.S. Department of Health and Human Services. Be assured that no retaliation or diminution of service will result if you file a complaint with the Director or us.

2. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of Protected Health Information (1) for treatment, payment, and health care operations, (2) to individuals (such as a family member, other relative, close personal friend, or any other person identified by you) involved with our care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. We will consider all requests for additional restrictions carefully but are not required to agree to a requested restriction. To request additional restrictions, ask our Privacy Officer for a request form and submit the completed form to the Privacy Officer.

3. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive Protected Health Information by alternative means of communication or at alternative locations, such as by mail to an address other than your home.

4. Right to Inspect and Copy your Health Information. You may request access to our records that we use for decision-making purposes about you and contain your Protected Health Information. You may request access in order to inspect and ask for copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If your request is denied, you will receive a written response and may request that the denial be reviewed. If you desire access to your records, please obtain a record request form from the Privacy Officer and submit the completed form to the Privacy Officer. If you request copies of your records, we are allowed to charge a fee for the costs of copying, mailing, or other services associated with your request. Determination of the fee will be made at the time your request is processed.

5. Right to Amend Your Records. You have the right to request an amendment to your Protected Health Information that we created and use for decision-making purposes. If you desire to amend your records, please obtain an amendment request form from the Privacy Officer and submit the completed form to the Privacy Officer. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other circumstances apply.

6. Right to Receive an Accounting of Disclosures. You may request an accounting of certain disclosures of Protected Health Information made by us. Your request must state the period of time desired for the accounting, which must be within the (6) years prior to the date of your request and exclude dates prior to April 14, 2003. If you desire to receive an accounting of disclosures, please obtain an accounting of disclosures request form from the Privacy Officer. If you request an accounting more than once during a twelve (12) month period, we may charge a fee based on the cost of fulfilling your request. You will be notified of the fee at the time of your request and will be given the opportunity to withdraw or modify your request.

7. Right to be Notified following a breach of unsecured PHI. You have the right to be notified following a breach of your unsecured PHI.

8. Right to Opt out of Fund Raising Communications. You may be contacted to raise funds; however, you have the right to opt out of receiving such communications.

9. Required Individual Authorizations. Most uses and disclosures of PHI for marketing purposes and sale of PHI require your individual authorization. Southwest Internal Medicine will not release your PHI without your written authorization.

10. Other Uses and Disclosures. Uses and disclosures not described in this Notice of Privacy Practices will be made only with authorization from you.

11. Right to Restrict Certain Disclosures of PHI. You have the right to restrict certain disclosures of PHI to a health plan when the individual or any person other than the health plan pays for the treatment at issue out of pocket and in full.

12. Right to Receive Paper Copy of This Notice. Upon request you may obtain a paper copy of this Notice.

VI. Effective Date and Duration of This Notice

1. Effective date. This notice describes the privacy policy of Southwest Internal Medicine that will become effective on April 14, 2003. Prior to that date Southwest Internal Medicine will continue to protect your Protected Health Information appropriately.

2. Right to Change Terms of This Notice. We may change this Notice at any time. If we do, the new Notice may apply to any information (including Protected Health Information) created or received prior to issuing the new Notice. This Notice is posted in the waiting area of our office. You also may obtain a copy of any Notice by contacting the Privacy Officer.

3. Southwest Internal Medicine’s address is 292 S. 1470 E. Suite 100, St. George, Utah 84790 (435) 628-9200.

Revised July 2013