1102 Water St., P. O. Box F
St. Edward, NE 68660
Mon Tue Wed Fri 8-5 Thu 8-12 Sat 9-12 (Closed 5th Sat)
103 S. 3rd St., P. O. Box 313
Cedar Rapids, NE 68627
Tue 9-5 Thu 9-5 Fri 9-12
COUNTRY CLINICS, P.C.
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. Our receptionist will ask you to sign an acknowledgement that you have received this notice.
I. What This Is
This Notice describes the privacy practices of Country Clinics, P.C. at both St. Edward Medical Clinic and Cedar Rapids Medical Clinic locations.
II. Our Privacy Obligations
We are required by law to maintain the privacy of medical and health information about you, referred to as "Protected Health Information" or "PHI", and to provide you with this Notice of our legal duties and privacy practices with respect to PHI. When we use or disclose PHI, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure). Although we have always maintained our patients' medical records in the strictest confidentiality, we are now required to give you this information in written form.
III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe in Section IV below, we must obtain your written authorizations in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:
A. Uses and Disclosures For Treatment, Payment and Health Care Operations. We may use and disclose PHI in order to treat you, obtain payment for services provided to you and conduct our "health care operations" (e.g. internal administration, quality improvement and customer service) as detailed below:
Treatment. We use and disclose PHI to provide treatment and other services to you - for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose PHI to other providers involved in your treatment. We may call you by name when you are in our organization, or call and leave messages on your answering machine unless instructed otherwise by you.
Payment. We may use and disclose PHI to obtain payment for services that we provide to you - for example, disclosures to claim and obtain payment from your health insurer, HMO or other company that arranges or pays the cost of some or all of your health care, or to verify that your insurance company will pay for health care.
Health Care Operations. We may use and disclose PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose PHI to our clinic manager in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.
We may also disclose PHI to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.
B. Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure. If you object to such uses or disclosures, please notify the Privacy Officer.
If you are not present, you are incapacitated, or in an emergency circumstance, we may exercise or professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or close personal friend, we would disclose only information that is directly relevant to the person's involvement with your health care or payment related to your health care. We may also disclose PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.
C. Public Health Activities. We may disclose PHI for the following public health activities, and are required by law to do so: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
D. Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect or domestic violence.
E. Health Oversight Activities. We may disclose PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
F. Judicial and Administrative Proceedings. We may disclose PHI in the course of a judicial or administrative proceeding in response to a legal order to other lawful process.
G. Law Enforcement Officials. We may disclose PHI to the police or other law enforcement officials for certain law enforcement purposes, including, but not limited to:
Reporting certain types of wounds and/or other physical injuries (i.e. gunshots)
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, or crime victims
Reporting and/or answering requests about a death we believe was crime-related
Reporting criminal conduct that took place on our premises
In emergency situations to report the location, identity, or description of a crime, a victim or person involved in the crime.
H. Decedents. We may disclose PHI to a coroner, medical examiner, or funeral director as authorized by law.
I. Organ and Tissue Procurement. We may disclose PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
J. Research. We may use or disclose PHI without your consent or authorizations if an Institutional Review Board/Privacy Board approves a waiver of authorization for disclosure.
K. Health or Safety. Consistent with applicable federal and state laws, we may use or disclose PHI to prevent or lessen a serious and imminent threat to a person's or the public's health or safety. We may also disclose PHI if it is necessary for law enforcement officials to identify or apprehend an individual.
L. Specialized Government Functions. We may use and disclose to units of the government with special functions, such as the U.S. military or the U.S. Department of State. When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of the foreign military services. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
M. Workers' Compensation. We may disclose PHI as authorized by and to the extent necessary to comply with Nebraska laws relating to workers' compensation or other similar programs.
N. As required by law. We may use and disclose PHI when required to do so by any other law not already referred to in the preceding categories.
O. Marketing Communications. We may use your PHI to send you any marketing materials such as newsletters about our practice and the services we offer. In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings. We may use or disclose your PHI to identify health related services or products that may be beneficial to your health and then contact you about the services and products. You may contact our Privacy Officer and request that these materials not be sent to you.
IV. Use and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described in Section III, we only may use or disclose PHI when you give us your authorization on our authorization form. For example, you will need to execute an authorization form before we can send your PHI to your life insurance company, to your child's camp or school, or to the attorney representing the other party in litigation in which you are involved.
B. HIV-Related Information. Confidential HIV-related information (for example, information regarding whether you have ever been the subject of an HIV test, have HIV infection, HIV-related illnesses or AIDS, or any information which could indicate that you have ever been potentially exposed to HIV) will never be used to disclosed to any person without your specific written authorization, except to certain other persons who need to know such information in connection with your medical care, and, in certain limited circumstances, to public health or other government officials (as required by law), to persons specified in a special court order, to insurers as necessary for payment for your care or treatment, or to certain persons with whom you have had sexual contact or have shared needles or syringes (in accordance with a specified process set forth in Nebraska State law). This special written authorization is a separate document from your authorization to release medical records as specified by Nebraska State law.
C. Psychotherapy, Substance Abuse-Related Information. Psychotherapy-related information or substance abuse-related information will never be used or disclosed to any person without your specific written authorization except in cases where the health and safety of another person or the public may be at risk. In these cases, the information will be released only to the proper law enforcement or government officials authorized to receive this information in accordance with Nebraska State law. This specific written authorization is a separate document from your authorization to release medical records as specified by Nebraska State law.
V. Your Individual Rights
A. For Further Information or to Register Complaints. If you desire further information about your privacy rights or have questions about any of the information contained in this Notice, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to PHI, you may contact our Privacy Officer listed in Section VII of this Notice. You may also file complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint with the Director or us.
B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of PHI (1) for treatment, payment and health care operations, (2) to individuals (such as family member, relative, close personal friend or any other person identified by you) involved with your 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. All requests for such restrictions must be made in writing. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from our Privacy Officer and submit the completed form to the Privacy Officer. We will send you a written response.
C. Right to Receive Confidential Communications. You may request, and will will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations. We will not request an explanation from you as to the basis of the request. Please make this request in writing.
D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, we may deny you access to your records. If you desire access to your records, please obtain a record request form from the receptionist and submit the completed form to the Privacy Officer. If you request copies, we will charge you a $20 base fee plus $.50 per page. We ask that you give us ten (10) days to copy your records.
You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor's medical record will not be accessible to you (for example, records relating to venereal disease, abortion, or care and treatment to which the minor is permitted to consent him/himself (without your consent) such as HIV testing, sexually transmitted disease diagnosis and treatment, chemical dependence treatment, prenatal care, care received by a married minor, and contraception and/or family planning services).
E. Right to Revoke Your Authorization. You may revoke your Authorization except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Officer identified below. A form of Written Revocation is available upon request from the Privacy Officer.
F. Right to Amend Your Records. You have the right to request that we amend PHI maintained in your medical record file or billing record. 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. All requests for amendments must be in writing. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
G. Right to Receive An Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you $5 per page of the accounting statement.
H. Right to Receive Paper Copy of this Notice. Upon written request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Effective Date. This notice is effective on April 14, 2003.
B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the revised notice in the waiting room of our offices and on our Internet site at www.megavision.com/stedmed. You may also obtain any revised notice by contacting the Privacy Officer.
VII. Privacy Officer
The Privacy Officer for Country Clinics is Vickie Fritzges, Clinic Manager.
You may contact the Privacy Officer in person at:
Country Clinics, P.C.
1102 Water St.
St. Edward, Nebraska
By mail at:
Country Clinics, P.C.
P. O. Box F
St. Edward, NE 68660
By Telephone or Fax:
Telephone: (402) 678-2232
Fax: (402) 678-2234
Or by e-mail at:
by McGee Designs, 1998-2003