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.
Effective: April 14, 2003
The physicians and staff of Urgent Medical & Family Care, PA (UMFC) are legally required to protect the privacy of your health information and to abide by the requirements stated in this document. This Notice of Privacy Practices describes our legal duty to protect the privacy of your health information and the policies and procedures this office has in place to do so.
Our office is required to prominently post the most current notice at all times. A copy of the current Notice of Privacy Practices for UMFC will be given to each patient on their first office visit. You will be asked to sign an acknowledgement that you received a copy. A copy of this notice will be provided to any individual upon request.
If you need additional information about anything contained in this notice please contact our practice administrator by calling 336-299-0000. We encourage you to ask questions about anything that you do not understand.
UMFC reserves the right to change its Notice of Privacy Practices without advance notice to you and apply the revised Notice of Privacy Practices to your health information. Any changes that are made will be highlighted on the most current Notice of Privacy Practices that is posted in our office so that they are easily recognized. If changes are made to this Notice of Privacy Practices, you will be provided with a copy of the revised Notice on your first visit following the revision.
UMFC has policies and procedures to insure that your health information is protected. These include specific guidelines for how and when your health information is used, when and how it is disclosed, how confidentiality is maintained, who has access to your health information, and when your health information can be shared with others.
Our office will use and disclose your health information to provide your care and treatment, bill and collect payment for services received and carry out the routine health care operations of this office. The uses and disclosures include but are not limited to the following:
Administrative functions within the office – assembling health information, filing records, scheduling appointments, reminding patients of appointments and other scheduled activities, billing and collecting for services Record creation, documentation and monitoring of your health status Communication among the workforce of this office, either verbally or in writing, information that is required for them to perform the functions of their job Consulting with other providers and their workforce, providing health information as required and making referrals Verifying your benefits and eligibility with your insurance company Obtaining authorization from your insurance company as required Calling in prescriptions to your pharmacy Providing health information as needed for scheduling appointments for diagnostic tests, surgery, admission, consultations, home health and other services that you require Providing health information to your insurance company as requested for their administrative requirements
Our office may contact you directly by phone, answering machine, fax, electronically or by mail for any of the following activities:
Providing follow-up reminders for this office. Scheduling follow-ups for this office and/or appointments with other offices as necessary and providing you with appointment information Describing or recommending treatment alternatives. Providing pre-test instructions and test results Providing information about health related benefits and services that may be of interest to you such as classes or educational opportunities
If UMFC needs to treat you in an emergency situation, you will be provided with a copy of the Notice after your emergency has been taken care of and a good faith effort will be made to obtain your acknowledgment of receipt of the Notice.
Your health information may be used and disclosed without your authorization in the following circumstances if you are informed and given the opportunity to agree or object. If you are not present or the opportunity for you to agree or object cannot be provided, we may decide whether the disclosure is in your best interest based on professional judgment.
To a family member or other relative, close personal friend, or other person identified by you, the health information relevant to that person’s involvement in your care or payment To a family member, close personal friend, a personal representative, or other person responsible for your care regarding your location, general condition or death To a public or private organization authorized by law to assist in disaster relief efforts as required by law
Your health information may be used and disclosed without your authorization or the opportunity for you to agree or object in the following circumstances as required by law.
For public health activities including but not limited to reporting of communicable diseases, reporting births and deaths, and public health surveillance as required by law For suspected child abuse and neglect as required by law To the Food and Drug Administration to report adverse events including adverse drug reactions and product defects or problems as required by law To your employer if you have a work related injury or illness or a workplace related medical surveillance as required by law To a government authority if you are a victim of abuse, neglect or domestic violence (You must be informed of such a report unless, in the exercise of professional judgment it puts you at risk of serious harm) as required by law To a health oversight agency as authorized by law including audits; civil, administrative or criminal investigations; inspections; licensure or disciplinary actions as required by law In response to a court order or court-ordered warrant, a subpoena or summons issued by a judicial officer, a grand jury subpoena or administrative request as required by law To law enforcement officials for the purpose of identifying or locating a suspect, fugitive, material witness or missing person as required by law To law enforcement officials if you are suspected to be a victim of a crime as required by law To law enforcement officials of a death if we suspect that the death may have resulted from criminal conduct as required by law To a coroner or medical examiner for the purpose of identification, determining a cause of death or other duties authorized by law To a funeral director as necessary to carry out their duties as required by law To organ procurement organizations engaged in procurement, banking or transplantation of cadaver organs, eyes, or tissue as required by law All other uses and disclosures of your health information will require your specific authorization.
You have the following rights regarding your health information:
The right to request restrictions on how your health information is used or disclosed. Every effort will be made to honor your request but we are not required to agree to a requested restriction The right to receive confidential communications of health information The right to see and receive a copy of your health information The right to request an amendment or correction to your health information The right to receive an accounting or list of each time your health information has been disclosed. The first accounting within a twelve-month period is provided at no cost to you. The provider may charge a reasonable cost-based fee for each subsequent request within the twelve month period If you believe your privacy rights have been violated, you may make a complaint to our office manager by calling 336-299-0000 or in writing to the office address. You may also make a complaint to the Secretary of Health and Human Services at the address listed below. If you make a complaint to the Secretary of Health and Human Services at the address listed below, the complaint must be in writing and contain the name of the physician or office, describe the act or omission believed to be in violation and must be filed within 180 days of the incident. You will not suffer any retaliation for filing a complaint.
Secretary of Health and Human Services
200 Independence Ave., SW
Washington, DC 20201
