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:

Ms. Amanda Sutphen

Medical Records Department

Foothill Family Practice Medical Group

440 West Foothill Blvd.

Glendora, Ca 91741

626 963 9402, extension 119

or

Ms. Patsy Scott

Office Coordinator

626 963 9402, extension 139

This notice will be posted in our front office, and will be available on our web site at www.4-ffpmg.com.  You may also request a written copy.  You will be asked to sign an acknowledgement form, acknowledging that you are aware that we have drawn up and have written a NOTICE OF PRIVACY PRACTICES.

Any FFPMG health care professional authorized to enter information into your medical chart. Some of our business partners to whom we outsource confidential medical information.

All FFPMG employees.

We understand that medical information about you and your health is personal and private.  We are committed to protecting your health information.  We create a record of your care and the services you receive at FFPMG.  We need this record to provide you with the best medical care. This Notice will tell you about the ways we use and disclose your protected health information.  It also informs you of our legal requirements and obligations, and describes your rights concerning the disclosure of your protected health information. 

We are required by law to:

· Make sure your protected medical information is kept private.

· Make available to you this Notice.

· Follow the terms of this Notice. (The notice may change, as described under CHANGES TO THIS NOTICE.)

The following categories describe the different ways we may use and disclose your protected medical information.  Where possible, for each category of uses or disclosure, we will provide an example.  The examples will not cover all the ways we use and disclose this information.  Our uses and disclosures, however, will all be covered by one of the categories.

FOR TREATMENT

We may use and disclose your medical information to provide you with medical treatment or services.  We may disclose this information to other doctors, nurses, technicians, medical students, or other personnel who are involved in your medical treatment.  For example, another doctor treating you may need to know if you have diabetes or high blood pressure, and what medicines you are taking.  If you are a patient in a hospital, that doctor may then need to tell a dietician about your diabetes so that an appropriate diet can be arranged.  Different hospital departments may share your information to coordinate your treatment plan.  The hospital pharmacy will need to know what medicines you are taking to ensure that added medications will not interact unfavorably with your current medications.

We may also disclose information about you to other doctors involved in your care.  For example, we may call your cardiologist about an abnormal lab result we obtained to determine the best advice to provide for you.  Or we may fax pertinent information to a consulting physician who will be seeing you in his/her office.  We may disclose your information to a hospice unit or home health agency that is treating you.

We may disclose your information to you in person, by mail, by telephone, or by fax.  If we contact your voice mail or answering machine, we will leave a non specific message.  ("This is Heather at Dr. Stuart’s office.  Please call us at your convenience.")  If your voice mail or answering machine message does not identify your phone number or your name, we may not leave any message.  Please be aware that faxed confidential information may be sent to an unsecure site.  For example, you may want us to fax information to a fax number at your office, where other individuals may have access to this information.

We will provide you with a "Request for Confidential Information Communication" form to complete.  This form will inform us how and to whom we may disclose your confidential information.  If you are unable to complete the form, we will attempt to obtain your verbal authorization before disclosure of information. 

We may disclose, unless you object, your protected information to a family member, relative, or close friend who is involved in your medical treatment.  (Objections are also discussed under the YOUR  RIGHTS category.)  For example, we may call your home and discuss with your husband, if you are not there, an abnormal result if such notification is necessary for a change in your treatment plan.

We may also use and disclose your medical information to notify or assist in notifying a family member, personal representative, or any other person responsible for your care of your location, general condition, or your death.  For example, we may notify your son that you are being directly admitted to the hospital from our office. We may notify your friend who brought you to the office that you are ready to go home.

FOR PAYMENT

Your protected health information will be used, as needed, to obtain payment for your health care services received at FFPMG.  We may bill your insurance company for services provided.  We may share your information with your insurance company to assist the company with its payment decisions.  They may need your protected information before they approve or pay for the services we recommend for you. They may need your information to assist in making a determination of your eligibility or coverage for insurance benefits, reviewing services provided to you for their medical necessity, and undertaking utilization review activities.  Examples include the need to share your medical information with the insurance company before they approve a certain diagnostic test or a certain medication that we request.  We may need to share your information before approval is received for a requested hospital stay. We may need to share information about that hospital stay with the insurance company so they will pay us or reimburse you for our services during that hospitalization.  We may share your demographic information with  collection agencies we choose to assist us in obtaining payment for our services. 

FOR HEALTH CARE OPERATIONS

We may use and disclose your protected information to support our business activities, which are necessary to run our office.  For example, we use a sign- in sheet at the registration window where you will be asked to sign your name and indicate which provider you are seeing.  We will call you by name in the waiting room when your provider is ready to see you.  We may use our automated telephone reminder program to call your home to remind you about an upcoming appointment.   

We may share your information with third party "business associates" that perform various activities for us, including, but not limited to pharmacy supply companies, medical transcription companies, and billing service companies.  Whenever an arrangement between our office and a business associate involves the use of your protected information, we will have a written contract that contains terms that insure the privacy of your information.

We may use and disclose your information to provide you with information about treatment alternatives and other health related information that may interest you.

We may release information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. 

Under certain conditions, we may use and disclose your information for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another medication.  We will almost always ask for your specific permission (on an authorization form) if the researcher will have access to your name, address, or other information that reveals who you are.

We may also use and disclose your information during utilization review procedures that help determine the appropriateness of your medical care.  For example, we may share information about your diabetes with your insurance company’s utilization review department so they can advise us if you are receiving the necessary tests and specialist consultations this disease requires.  Or we may notify you of a medication change your pharmacy supplier is requesting to better help comply with your prescription drug benefit. 

SPECIAL SITUATIONS

AS REQUIRED BY LAW.  We will disclose medical information about you when required to do so by federal, state, or local law.  For example, we are required to report any lapse of consciousness disorders to the Health Department.

LAW ENFORCEMENT.  We may release medical information if asked to do so by a law enforcement official:

· In response to a court order, subpoena, warrant, or similar process.

· To identify or locate a suspect, fugitive, material witness, or missing person. 

· About the victim of a crime, if under limited circumstances, we are unable to obtain the persons agreement.

· About a death we believe may be the result of criminal conduct.

· About criminal conduct at FFPMG.

· In emergency circumstances to report a crime, the location of the crime, or the identity, description, or location of the person who committed the crime.

NATIONAL SECURITY, INTELLIGENCE, AND FEDERAL PROTECTIVE SERVICE ACTIVITIES.  We may release information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities as authorized by Federal Law.

TO AVERT A SERIOUS THREAT TO YOUR  HEALTH AND SAFETY, OR THE  HEALTH AND SAFETY OF OTHERS.  We may use and disclose your information when necessary to prevent a serious threat to your health and safety or the health and the safety of another person.  For example, we may notify the police or the emergency psychiatric team if you inform one of our staff that you are going to end your life.

EMERGENCIES.  We may use or disclose your protected information in an emergency treatment situation.  We will try to obtain your consent as soon as possible after treatment is rendered.  For example, we will call 911 if you become unconscious in our office, and we may inform other doctors involved in your care at the hospital about you. 

ORGAN AND TISSUE DONATION.  If you are an organ donor, we may release information about you to facilitate organ donation.

MILITATY/VETERANS AFFAIRS.  If you are a member of the armed forces, we may release information about you as requested by military command authorities or we may release requested information to the Department of Veterans Affairs.

WORKERS COMPENSATION/DISABILITY.   We may release medical information about you to your workman’s compensation carrier or disability insurance carrier.  For example, if you are receiving disability benefits, we will need to provide the carrier with periodic updates about your condition. 

PUBLIC HEALTH RISKS.  We may disclose information about you to a public health agency:

· To prevent or control disease, injury, or disability.  For example, we are required to report cases of hepatitis B to the County Health Department.  Should you be diagnosed as having hepatitis B, we would send information about you to the health department.    

· 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 spreading a disease.

· To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.  

CORONERS, MEDICAL EXAMINERS, AND FUNERAL DIRECTORS.  We may disclose your protected information to a coroner or medical examiner.  This information may be necessary to determine the cause of death. 

INMATES.  If you are an inmate of a correctional institution, we may release your medical information to the appropriate officials to provide continuity of medical care and to protect the health and safety of others.  For example if you are arrested and taken to jail but are under treatment for tuberculosis, we would notify the proper authorities about your condition.

LAWSUITS AND DISPUTES.  If you are involved in a lawsuit or a dispute, we may disclose information about you in response to a court or administrative order.  We may also disclose information is response to a subpoena, discovery request, or other lawful process but only if efforts have been made inform you about the request.

You have the following rights regarding your protected medical information.

RIGHT TO INSPECT AND COPY 

You have the right to inspect and copy your protected medical information.  Usually this includes medical and billing records, but does not include psychotherapy records. 

You must submit any request to inspect and copy your information to our Medical Records Department or to our Office Coordinator.  Their phone numbers are listed on the first page of this notice.  You may also ask your provider of care or their medical assistant about this right.  They will direct you to the Medical Records Department.

A form will be provided to you to request this inspection in writing.  We may charge a fee for the costs of reviewing and copying this information.  We may also charge a fee should an office visit be needed to accomplish the inspection.  Please be aware this is not a covered benefit under your insurance plan.  You will be responsible for this charge.

Our records are kept for ten years for adults and eighteen years for children. 

We may deny your request in certain circumstances.  If your request is denied, you may request that the denial be reviewed.  Another licensed health care professional chosen by FFPMG will review the request and denial.  We will comply with the outcome of that review.  We will attempt to comply with your request within thirty days.  If we are unable to comply with the time deadline, we will notify you in writing of the reason for noncompliance.

THE RIGHT TO AMEND YOUR RECORD

You have the right to request amendments to your protected medical information if you believe that the information is incorrect.  This right remains in effect for as long as we keep your records. 

You must submit any request for an amendment to our Medical Records Department or to our Office Coordinator.  The Records Department has the necessary request to amend form.  Your written request must provide a reason that supports your request. 

We may deny your request for an amendment if it is not in writing or does not include a reason that supports your request.  In addition, we may deny a request to amend information that:

Was not created by us.  For example, we will not amend a consultation report from another doctor.  If that doctor is unavailable, we may add your amendment request to your chart.

· Is not part of your FFPMG protected medical information.

· Is not part of the information that you are permitted to inspect or copy.

· We believe is accurate and complete.

· We will notify you in writing of our reason for denial. 

RIGHT TO AN ACCOUNTING OF DISCLOSURES

You have the right to know, with exceptions, the persons and entities to whom we disclose your protected medical information.  The exceptions include disclosures we have made to you, and routine disclosures for treatment, payment and health care operations.  We will keep a log of the disclosures for which we have had to obtain your authorization.  You have the right to review this log.

You must submit any request for an accounting of disclosures to our Medical Records Department or to our Office Coordinator.  A form for that request is available.  Your request must indicate the approximate time period of the involved disclosures.  The first report you request within a twelve month period will be free.  We may charge you for additional reports.  We will notify you of the cost.

RIGHT TO REQUEST RESTRICTIONS

You have the right to request a restriction or limitation on the medical information that we use or disclose about you for treatment, payment, or health care operations.  You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your medical care or is involved in the payment for your care.  For example, you could ask us to not disclose to your mother's information about a recent surgery that you had.  Or you may request that we do not notify your daughter about a group of lab tests that were performed on a specific date.  Or, if you saw us for two problems, hypertension and back pain, on a specific date, you could ask us not to disclose the hypertension problem to your insurance company.  However, please be aware that you have likely signed a release of information form with your insurance carrier, authorizing them to review your medical record and if needed, to request confidential information from us.  We cannot falsify our records or submit fraudulent claims. 

You must submit in writing any requests for restrictions to our Medical Records Department or to our Office Coordinator.  A form for these requests is available.  You may ask your provider of care, their medical assistant, or the medical records department personnel for the form.  Your request must tell us:

· What information you want to limit.

· Whether you want to limit our use, our disclosure, or both or use and disclosure of your protected information.

· To whom you want the limits to apply.

Please note that we are not required to agree to your request.  If we do agree, we will comply with your request.  Please also note that we cannot falsify our records, or attempt any fraudulent billing procedures.  If you saw us for hypertension and back pain, we cannot bill your insurance company for a visit for bronchitis.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATION

We have previously discussed how we will communicate with you (discussed under the DISCLOSURE section.)  We will provide you with a form requesting your written input about communication and disclosure of confidential information.  If we have not had your written input on this issue, we will attempt to receive your verbal authorization for disclosure.

You have the right to request that we communicate with you about your medical information in a specific way or at a specific time or location.  For example, you may request that we only notify you at work.  Or you may request that we send your results to your college dorm address and not to your home.  Or you may request that we do not reveal any information to any family member.  

RIGHT TO RECEIVE A PAPER COPY OF THIS NOTICE

You may ask to receive a paper copy of this Notice.  We will comply with this request.  You may also obtain a copy of this Notice, and obtain the necessary forms that are required to be completed, at our website.  Our website address is listed on the first page of this Notice. 

We reserve the right to change this Notice.  When we do, we may make the changed Notice effective for protected information we already have about you as well as your current and future medical information.  We will post the revised Notice in the same manner as listed previously, and make copies of the revised Notice available to you.

If you believe that your privacy rights have been violated, you may file a complaint with FFPMG or you may contact the Secretary of the Department of Health and Human Services.  To file a complaint please contact our Medical Records personnel or contact our Office Coordinator.  You will not be penalized for filing a complaint.

HIPPA 2-25-03 R3

Copyright © 2004 Foothill Family Practice
Last modified: 04/06/04