HIPPA NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
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.
If you have any questions about this notice,
please contact our Privacy Officer at (260) 490-2525
WHO WILL FOLLOW THIS NOTICE:
This notice describes Pain Management Associates Policies and Procedures and
- Any health care professional authorized to enter information into your medical record.
- Any member of a volunteer group we allow to help you while you are in the practice.
- All employees, staff and other practice personnel.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
Pain Management Associates understands that medical information about you
and your health is personal. Pain Management Associates is committed to
protecting medical information about you. Pain Management Associates creates
a record of the care and services you receive at the practice. We need this
record to provide you with quality care and to comply with certain legal
requirements. This notice applies to all of the records of your care
generated by the practice, whether made by practice personnel or your
personal doctor. This notice will tell you about the ways in which we may
use and disclose medical information about you. We also describe your rights
and certain obligations we have regarding the use and disclosure of medical
Law to require us:
- Make sure that medical information that identifies you is kept private;
- Give you this notice of our legal duties and privacy practices with
respect to medical information about you; and
- Follow the terms of the notice that is currently in effect.
HOW PAIN MANAGEMENT ASSOCIATES MAY USE AND DISCLOSE
MEDICAL INFORMATION ABOUT YOU:
The following categories describe different ways that Pain Management
Associates may use and disclose medical information. For each category of
uses or disclosures we will explain what we mean. Not every use or
disclosure in a category will be listed. However, all of the ways we are
permitted to use and disclose information will fall within one of the
For Treatment: Pain Management Associates may use medical information about
you to provide you with medical treatment or services. Pain Management
Associates may disclose medical information about you to doctors, nurses,
technicians, medical students, or other personnel who are involved in taking
care of you at the practice. We also may disclose medical information about
you to people outside the practice who may be involved in your medical care
after you leave the practice, such as family members, clergy or others we
use to provide services that are part of your care. In the course of your
treatment, verbal communications between Pain Management Associates staff
members and others related to your healthcare may be overheard by non-staff
members in our office. Pain Management Associates will make their best
efforts to keep your health information as private as possible.
For Payment: Pain Management Associates may use and disclose medical
information about you so that the treatment and services you receive at the
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 treatment you received at the practice so your
health plan will pay us or reimburse you for the treatment. We may also tell
your health plan about a treatment you are going to receive to obtain prior
approval or to determine whether your plan will cover the treatment.
For Health Care Operations: We may use and disclose your medical information
in connection with our health care operations. Health care operations
include quality assessment and improvement activities, reviewing the
competence or qualifications of health care professionals, evaluating
practitioner and provider performance, conducting training programs,
accreditation, certification, licensing or credentialing activities.
Appointment Reminders: Pain Management Associates may use and disclose
medical information to contact you (either by telephone, answering machine,
or leaving a message with a family member at your residence) as a reminder
that you have an appointment for treatment or medical care at our practice.
Answering Phone Messages: In addition to appointment times, there are some
situations where it may be necessary to leave information on your answering
phone or voicemail if you are not at home or immediately available by
telephone. Our staff may leave specific instructions on your answering phone
or voicemail regarding your lab results and any necessary changes in your
medication. If you do not wish to have any information left on your
answering phone or voicemail or you would like an alternate method for
communicating this type of information, you must request this in writing and
we will discuss this with you to make other arrangements.
Treatment Alternatives: Pain Management Associates may use and disclose
medical information to tell you about or recommend possible treatment
options or alternatives that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care: Pain Management Associates may release medical information about you to a friend or family member who is involved in your medical care. Pain Management Associates may
also give information to someone who helps pay for your care. Pain Management Associates may also tell your family of your condition. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, medical supplies, x-rays, or other similar forms of medical information.
As Required By Law: Pain Management Associates will disclose medical
information about you when required to do so by federal, state or local law.
Abuse or Neglect: We may disclose your medical information to appropriate
authorities if we reasonably believe that you are a possible victim of
abuse, neglect, or domestic violence or the possible victim of other crimes.
We may disclose your medical information to the extent necessary to avert a
serious threat to your health or safety or the health or safety of others.
We may disclose medical information when necessary to assist law enforcement
officials to capture an individual who has admitted to participation in a
crime or has escaped from lawful custody.
Military and Veterans: If you are a member of the armed forces, we may
release medical information about you as required by military command
authorities. We may also release medical information about foreign military
personnel to the appropriate foreign military authority. We may use and
disclose to components of the Department of Veterans Affairs medical
information about you to determine whether you are eligible for certain
Workers¹ Compensation: Pain Management Associates may release medical
information about you for workers¹ compensation or similar programs. These
programs provide benefits for work related injuries or illness.
Public Health Risks: Pain Management Associates may disclose medical
information about you for public health activities. These activities
generally include the following:
- To prevent or control disease, injury and 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 of 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 make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities: Pain Management Associates may disclose medical
information to a health oversight agency for activities authorized by law.
These oversight activities include, for example, audits, investigations,
inspections, and licensure. These activities are necessary for the
government to monitor the health care system, government programs, and
compliance with civil rights law.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may
disclose medical information about you in response to a court or
administrative order. We may also disclose medical 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
Law Enforcement: Pain Management Associates may release medical information
if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances,
we are unable to obtain the person¹s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the practice; and
- In emergency circumstances to report a crime; the location of the
crime or victims; or the identity, description or location of the person
who committed the crime.
Coroners, Medical Examiners and Funeral Directors: Pain Management
Associates may release medical information to a coroner or medical examiner.
This may be necessary, for example, to identify a deceased person or
determine the cause of death.
National Security and Intelligence Activities: Pain Management Associates
may release medical information about you to authorized federal officials
for intelligence, counterintelligence, and other national security
activities authorized by law.
Protective Services for the President and Others: Pain Management Associates
may disclose medical information about you to authorized federal officials
so they may provide protection to the President, other authorized persons or
foreign heads of state or conduct special investigations.
Inmates: 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 or the health and safety
of others; or (3) for the safety and security of the correctional
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU:
You have the following rights regarding medical information we maintain
Right to Inspect and Copy: You have the right to inspect and copy medical
information that may be used to make decisions about your care. Usually,
this includes medical and billing records, but does not include
To inspect and copy medical information that may be used to make decisions
about you, you must submit your request in writing to Pain Management
Associates medical records department. If you request a copy of the
information, Pain Management Associates medical records department charge a
fee of $15 for pages 1-10 and $.25 per page after 10 pages for the costs of
copying, mailing or other supplies associated with your request.
Pain Management Associates may deny your request to inspect and copy in
certain very limited circumstances. If you are denied access to medical
information, you may request that the denial be reviewed. 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 request. We will comply with the outcome of the
Right to Amend: If you feel that medical information we have about you is
incorrect or incomplete, you may ask us to amend the information. You have
the right to request an amendment for as long as the information is kept by
or for the practice.
To request an amendment, your request must be made in writing and submitted
to the office. In addition, you must provide a reason that supports your
Pain Management Associates 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
- Was not created by us, unless the person or entity that created the
information is no longer available to make the amendment;
- Is not part of the medical information kept by or for the practice;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
Right to an Accounting of Disclosures: You have the right to request an
³accounting of disclosures.² This is a list of the disclosures we made of
medical information about you outside of treatment, payment, operational
purposes and without an authorization.
To request this list or accounting of disclosures, you must submit your
request in writing to our office. Your request must state a time period,
which may not be longer than six years and may not includes dates before
April 14, 2003. The first list you request within a 12-month period will be
free. For additional lists, we may charge you for the costs of providing the
list. We will notify you of the cost involved and you may choose to withdraw
or modify your request at that time before any costs are incurred.
Right to Request Restrictions: You have the right to request a restriction
or limitation on the medical information we use or disclose. 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,
like a family member or friend. For example, you could ask that we not use
or disclose information about a surgery you had.
We are not required to agree to your request. If we do agree, we will comply
with your request unless the information is needed to provide you emergency
To request restrictions, you must make your request in writing to our
office. In your request, you must tell us (1) what information you want to
limit; (2) whether you want to limit our use, disclosure or both; and (3) to
whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications: You have the right to request
that we communicate with you about medical matters in a certain way or at a
certain location. For example, you can ask that we only contact you at work
or by mail.
To request confidential communications, you must make your request in
writing to our office. We will not ask you the reason for your request. We
will accommodate all reasonable requests. Your request must specify how or
where you wish to be contacted.
Right to a Paper Copy of this Notice: You have the right to a paper copy of
this notice at any time. To obtain a paper copy of this notice, please
contact our Privacy Officer at (260) 490-2525.
CHANGES TO THIS NOTICE:
Pain Management Associates reserves the right to change this notice. We
reserve the right to make the revised or changed 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 notice in the
practice office. The notice will contain on the first page, in the top
right-hand corner, the effective date. In addition, each time you register
for treatment or health care services as an outpatient, we will offer you a
copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a
complaint with the practice or with the Secretary of the Department of
Health and Human Service. To file a complaint with the practice, contact the
Privacy Office of Pain Management Associates. All complaints must be
submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION:
Other uses and disclosures of medical information not covered by this notice
or the laws that apply to us will be made only with our written permission.
If you provide us permission to use or disclose medical information about
you, you may revoke that permission, in writing, at any time. If you revoke
your permission, we will no longer use or disclose medical information about
you for the reasons covered by your written authorization. You understand
that we are unable to take back any disclosures we have already made with
your permission, and that we are required to retain our records of the care
that we provided to you.