ROCKY MOUNTAIN MEN’S CLINIC 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 read it carefully.
Rocky Mountain Men’s Clinic will gather certain health information about you and will create a record of the care provided to you. Other individuals or organizations that are part of your “circle of care”- such as the referring physician, your other healthcare providers, your health plan, and close friends or family members – may also share information with us. We may also use or share your health information with other parties for a variety of important purposes, including some purposes described below.
Rocky Mountain Men’s Clinic is committed to protecting the privacy and confidentiality of your health information. In keeping with this commitment, this Notice describes the privacy practices of our physicians, employees and other staff members at all of our service sites. Federal law requires that we: (i) maintain the privacy of medical information provided to us; (ii) provide this Notice of our legal duties and privacy practices to you; and (iii) abide by the terms of this Notice currently in effect.
We reserve the right to make changes to this notice at any time, and to make such changes effective for personal health information we have about you as well as any information we receive in the future. In the event there is a material change to this Notice, the revised Notice will be posted and made available to you upon request.
HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU
We may use and disclose personal and identifiable health information about you in different ways.
All of the ways in which we may use and disclose information without your prior permission will fall within one of the following listed categories, although not every possible use or disclosure falling within a category will be listed. We are required to obtain your written authorization for any other uses and disclosures of your health information not listed below. If you provide us with such permission, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by your written authorization; however, we will be unable to take back any disclosures already made based upon your original permission.
1. Treatment. We will use health information about you to furnish healthcare services and supplies to you, in accordance with our policies and procedures. We may also communicate with other healthcare providers to coordinate or manage your healthcare. For example, we will use your medical history, such as any presence or absence of prostate-related issues, to assess your health and perform requested diagnostic services.
2. Treatment Alternatives. We may use and disclose your personal health information in order to tell you about or recommend possible treatment options, alternatives or health-related services that may be of interest to you.
3. Individuals Involved in Your Care or Payment for Your Care/Disaster Relief. We may disclose health information about you (i) to a relative, close personal friend, or any other person you identify as part of your “circle of care,” if the information is directly relevant to their involvement in your care; or (ii) to the above individuals or a disaster relief organization (such as the Red Cross), if we need to notify someone about your location or condition. You may object to any of these disclosures, and if you object, we will not disclose the information except in certain circumstances such as an emergency.
4. Waiting Rooms – We may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when we are ready to begin your treatment.
5. Payment. We will use and disclose health information about you to bill for our services and to collect payment from you or your insurance company. For example, we may need to give payer information about your current medical condition so that we may receive payment for the examinations or other services that we have furnished you.
6. Health Care Operations. We will use and disclose your health information to conduct the business activities of our organization. These activities include, but are not limited to, quality assessment and improvement activities, review of the performance and qualifications of employees, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
7. Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment or that you should schedule an appointment.
8. Business Associates. We sometimes work with outside individuals and businesses that help us operate our business successfully. We may disclose your health information to these business associates so that they can perform the tasks that we hire them to do. Our business associates must provide us with certain written assurances that they will respect the confidentiality of your personal and identifiable health information.
9. Required by Law. We may disclose health information about you when we are required to do so by federal, state, or local law, subject to the limitations of such law and the physician-patient privilege, as applicable.
10. Public Health. We may disclose protected health information (PHI) about you in connection with certain public health reporting activities. For instance, we may disclose such information to a public health authority authorized to collect or receive PHI for the purpose of preventing or controlling disease, injury or disability, or, at the direction of a public health authority, to an official of a foreign government agency that is acting in collaboration with a public health authority. Public health authorities include state health departments, the Center for Disease Control, the Food and Drug Administration, the Occupational Safety and Health Administration and the Environmental Protection Agency, to name a few. We are also permitted to disclose protected health information to a public health authority or other government authority authorized by law to receive reports of child abuse or neglect. Additionally we may disclose protected health information to a person subject to the Food and Drug Administration’s power for the following activities: to report adverse events, product defects or problems, or biological product deviations, to track products, to enable product recalls, repairs or replacements, or to conduct post marketing surveillance.
11. Abuse Neglect or Domestic Violence. We may disclose your protected health information in situations of domestic abuse or neglect or abuse of persons other than children.
12. Healthcare Oversight. We may disclose protected health information in connection with certain health oversight activities of licensing and other agencies. Health oversight activities include audit, investigation, inspection, licensure or disciplinary actions, and civil, criminal, or administrative proceedings or actions or any other activity necessary for the oversight of 1) the health care system, 2) governmental benefit programs for which health information is relevant to determining beneficiary eligibility, 3) entities subject to governmental regulatory programs for which health information is necessary for determining compliance with program standards, or 4) entities subject to civil rights laws for which health information is necessary for determining compliance.
13. Law Enforcement. We may disclose certain information in response to a warrant, subpoena, or other order of a court or administrative hearing body, and in connection with certain government investigations and law enforcement activities.
14. Decedents Information. We may release personal health information to a coroner or medical examiner to identify a deceased person or determine the cause of death, or to funeral directors. We also may release personal health information to organ procurement organizations, transplant centers, and eye or tissue banks.
15. Workers Compensation. We may release certain personal health information to workers’ compensation or similar programs.
16. Serious Threats to Health or Safety. Information about you also will be disclosed when necessary to prevent a serious threat to your health and safety or the health and safety of others.
17. Research. We may use or disclose certain personal health information about your condition and treatment for research purposes where an Institutional Review Board or a similar body referred to as a Privacy Board determines that your privacy interests will be adequately protected in the study. We may also use and disclose your protected health information to prepare or analyze a research protocol and for other research purposes.
18. Armed Forces and other Government Functions. If you are a member of the Armed Forces, we may release personal health information about you as required by military command authorities. We also may release personal health information about foreign military personnel to the appropriate foreign military authority. We may also disclose protected health information for national security and intelligence activities and for the provision of protective services to the President of the United States and other officials or foreign heads of state.
19. Judicial or Administrative Proceedings. We may disclose your protected health information for legal or administrative proceedings that involve you. We may release such information upon order of a court or administrative tribunal. We may also release protected health information in the absence of such an order and in response to a subpoena, discovery request or other lawful request, if certain steps have been taken to notify you or secure a protective order.
20. Inmates. If you are an inmate, we may under certain circumstances disclose protected health information about you to a correctional institution where you are incarcerated or to certain law enforcement officials.
OTHER USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you. Any use or disclosure of psychotherapy notes, uses and disclosures of PHI for marketing purposes and disclosures that constitute the sale of PHI require your written authorization. If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing by contacting us at the address below. If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures which were being processed before we received your cancellation.
You have the following rights with respect to your health information. To exercise any of your rights, please contact us at:
Rocky Mountain Men’s Clinic
Attn: Privacy Officer
1780 Bellaire Street, Suite 355
Denver, CO 80222
1. You have the right to ask for restrictions on the ways in which we use and disclose your medical information beyond those imposed by law. We will consider your request, but we are not required to agree to it. However, we do have to agree if you request that we not disclosure your PHI to your health plan for health services or items for which you paid out-of-pocket in full. You may request a restriction by sending your request in writing to our Privacy Officer.
2. You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail. We will try to accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing by contacting our Privacy Officer.
3. Except under certain circumstances, you have the right to access, inspect and copy medical and billing records about you. A reasonable cost-based fee will be charged for expenses such as staff time, copying, and mailing. Contact us as indicated at the end of this Notice to obtain information about our fees or if you have any questions about accessing your health information. All requests must be sent in writing to the Privacy Officer.
4. If you believe that certain information in your records is incorrect or incomplete, you have the right to ask us to correct or supplement the records. Under certain circumstances, we may deny your request.
5. You have a right to ask for a list of certain instances when we have used or disclosed your medical information. If you ask for this information from us more than once every twelve months, we will charge you a reasonable cost-based fee for each request.
6. You have the right to a copy of this Notice in paper form, even if you have agreed to accept this notice electronically. You may ask us for a copy at any time. You may also obtain a copy of this form at our web site http://rockymountainmensclinic.com/.
7. You have the right to be notified in the event that we discover a breach of unsecured PHI involving your medical information.
If you have any questions, concerns or want to obtain more information concerning this Notice of Privacy Practices, you may contact our Privacy Officer at the address and telephone number listed above.
If you are concerned that we may have violated your privacy rights or you disagree with a decision we have made regarding your access to your health information or any other request you have made in the exercise of your rights, you may complain to our Privacy Officer at the address and telephone number above, or you may complain in writing to the federal government at the
following address: Region IV, Office for Civil Rights, U.S. Department of Health And Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth Street, SW, Atlanta, Georgia 30303-8909. We support your right to the privacy in your health information and we will not retaliate against you in any way for filing a complaint.
Effective Date: January 21, 2014.