Health Insurance Portability and Accountability Act of 1996 (HIPAA)
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.
Family Planning Specialists Medical Group, Inc. ("FPS") is committed to protecting the privacy of your health record and the confidentiality of your visit. Your healthcare record, known as a chart, and the information it contains will not be disclosed to any one or any agency outside of FPS without written authorization from you unless such a release is required by law.
FPS will use your health information for the purpose of:
| • |
Treatment For example, information obtained by a healthcare provider or staff member will be recorded in your record and used to determine the best course of treatment for you. |
| • | Payment For example, a bill may be sent to you or to a third party payer. The information on the bill may include information that identifies you, as well as your diagnosis, procedure, and supplies used. |
| • | Regular Healthcare
Operations For example, members of the medical staff or the quality improvement/risk management staff may use information in your health record to assess the care you received and outcomes of your care. This information will then be used in the Continuous Quality Improvement program of FPS. |
| • | Business Associates FPS provides some services through contracts with business associates. An example is a laboratory. To protect your health information, however, we require the business associate to appropriately safeguard your information. |
Disclosures required by law:
| • | Food
and Drug Administration (FDA) As required by law, FPS may disclose to the Food and Drug Administration (FDA) health information relative to adverse events with respect to product defects, product recalls, repairs or replacement. |
| • | Public Health FPS may disclose your health information, as required by law, to public health or legal authorities charged with preventing or controlling disease, injury or disability. |
| • | Law enforcement FPS may disclose health information for law enforcement purposed as required by law or in response to a valid subpoena. |
Your Health Information Rights
Although your health record is the physical property of FPS, the information it contains belongs to you. You have the right to:
| • | Request a restriction on certain uses and disclosures of your information |
| • | Obtain a paper copy of the notice of information practices upon request |
| • | Inspect a copy of your health record |
| • | Amend your health record as provided in 45 CFR 164.528 |
| • | Obtain an accounting of disclosures of your health information |
| • | Request communication of your health information by alternative means or at alternative locations |
| • | Revoke your authorization to use or disclose health information except to the extent that action has already been taken |
Our Responsibility
| FPS is required to: | |
| • | Maintain the privacy of your health information |
| • | Provide you with a notice as to FPS’ legal duties and privacy practices with respect to information FPS collects and maintains about you |
| • | Abide by the terms of this notice |
| • | Notify you if FPS is unable to agree to a requested restriction |
| • | Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations |
FPS reserves the right to change practices and to make the new provisions effective for all protected health information FPS maintains. Should FPS’ information practices change, we will make a reasonable effort to notify you of this change.
For More Information or to Report a Problem
If you have questions, or if you want to report a problem, please contact Tammy, FPS’ Privacy Officer at 510-268-3720. Complaints may also be filed with the Secretary of Health and Human Services, an act for which no retaliation will occur.
I have read this privacy notice and I have been given ample time to ask questions regarding the information it contains. I understand Family Planning Specialists will hold my record to the highest standard of privacy and confidentiality and will only release my personal health information when so authorized by me in writing, or when required by law to do so.
| ____________________________________ | __________________ | |
| Signature | Date |
| © 2002-2010 Family Planning Specialists Medical Group All Rights Reserved. |
