Notice of Privacy Practices
FORT WAYNE DERMATOLOGY
All Locations and Subsidiaries
This notice describes how medical information about
you may be used and disclosed and how you can gain
access to this information. Please review it carefully.
Notice of Privacy Practices
Protected health information, about you, is maintained
as a record of your contacts or visits for healthcare
services with Fort Wayne Dermatology. Specifically,
"protected health information" is information
about you, including demographic information (i.e.,
name, address, phone, etc.), that may identify you
and relates to your past, present or future physical
or mental health condition and related health care
services.
Fort Wayne Dermatology is required to follow specific
rules on maintaining the confidentiality of your
protected health information, using your information,
and disclosing or sharing this information with
other healthcare professionals involved in your
care and treatment. This Notice describes your rights
to access and control your protected health information.
It also describes how we follow applicable rules
and use and disclose your protected health information
to provide your treatment, obtain payment for services
you receive, manage our health care operations and
for other purposes that are permitted or required
by law.
We are required to abide by the terms of this Notice
of Privacy Practices. We reserve the right to change
the terms of our notice, at any time. The new notice
will be effective for all protected health information
that we maintain at that time. Upon your request,
we will provide you with any revised Notice of Privacy
Practices by calling the office and requesting that
a revised copy be sent to you in the mail or asking
for one at the time of your next appointment.
If you have any questions about this Notice, please
contact our Privacy Manager at (260) 436-8000 extension
*298.
Your Rights Under The Privacy Rule
Following is a statement of your rights, under the
Privacy Rule, in reference to your protected health
information. Please feel free to discuss any questions
with our staff.
* You have the right to receive, and we are required
to provide you with, a copy of this Notice of Privacy
Practices
We are required to follow the terms of this notice.
We reserve the right to change the terms of our
notice, at any time. If needed, new versions of
this notice will be effective for all protected
health information that we maintain at that time.
Upon your request, we will provide you with a revised
Notice of Privacy Practices. If you call our office
a copy can be sent to you in the mail or ask for
one at the time of your next appointment.
* You have the right to authorize other use and
disclosure
This means you have the right to authorize or
deny any other use or disclosure of protected health
information that is not specified within this notice.
You may revoke an authorization, at any time, in
writing, except to the extent that your physician
or our office has taken an action in reliance on
the use or disclosure indicated in the authorization.
* You have the right to designate a personal representative
This means you may designate a person with the
delegated authority to consent to, or authorize
the use or disclosure of protected health information.
* You have the right to inspect and copy your
protected health information
This means you may inspect and obtain a copy of
protected health information about you that is contained
in your patient record.
* You have the right to request a restriction
of your protected health information
This means you may ask us, in writing, not to
use or disclose any part of your protected health
information for the purposes of treatment, payment
or healthcare operations. You may also request that
any part of your protected health information not
be disclosed to family members or friends who may
be involved in your care or for notification purposes
as described in this Notice of Privacy Practices.
In certain cases, we may deny your request for a
restriction.
* You may have the right to request an amendment
to your protected health information
This means you may request an amendment of your
protected health information for as long as we maintain
this information. In certain cases, we may deny
your request for an amendment.
* You have the right to request a disclosure accountabilit
y
This means that you may request a listing of disclosures
that we have made, of your protected health information,
to entities or persons outside of our office.
How We May Use or Disclose Protected Health Information
Following are examples of uses and disclosures of
your protected health care information that the
we are permitted to make. These examples are not
meant to be exhaustive, but to describe the types
of uses and disclosures that may be made by our
office.
* Treatment
We may use and disclose your protected health
information to provide, coordinate, or manage your
healthcare and any related services. This includes
the coordination or management of your healthcare
with a third party that is involved in your care
and treatment. For example, we would disclose your
protected health information, as necessary, to a
pharmacy that would fill your prescriptions. We
will also disclose protected health information
to other physicians who may be involved in your
care and treatment.
We may also call you by name in the waiting room
when your physician is ready to see you. We may
use or disclose your protected health information,
as necessary, to contact you to remind you of your
appointment. We may contact you by phone or other
means to provide results from exams or tests and
to provide information that describes or recommends
treatment alternatives regarding your care. Also,
we may contact you to provide information about
health related benefits and services offered by
our office.
* Payment
Your protected health information will be used,
as needed, to obtain payment for your healthcare
services. This may include certain activities that
your health insurance plan may undertake before
it approves or pays for the healthcare services
we recommend for you such as; making a determination
of eligibility or coverage for insurance benefits,
reviewing services provided to you for medical necessity,
and undertaking utilization review activities.
* Healthcare Operations
We may use or disclose, as-needed, your protected
health information in order to support the business
activities of our practice. This includes, but is
not limited to business planning and development,
quality assessment and improvement, medical review,
legal services, and auditing functions. It also
includes education, provider credentialing, certification,
underwriting, rating, or other insurance-related
activities. Additionally, it includes business administrative
activities such as customer service, compliance
with privacy requirements, internal grievance procedures,
due diligence in connection with the sale or transfer
of assets, and creating de-identified information.
Other Permitted and Required Uses and Disclosures
We may also use and disclose your protected health
information in the following instances as outlined
below. You have the opportunity to agree or object
to the use or disclosure of all or part of your
protected health information.
* To Others Involved in Your Healthcare
Unless you object, we may disclose to a member
of your family, a relative, a close friend or any
other person that you identify, your protected health
information that directly relates to that person’s
involvement in your healthcare. If you are unable
to agree or object to such a disclosure, we may
disclose such information as necessary if we determine
that it is in your best interest based on our professional
judgment. We may use or disclose protected health
information to notify or assist in notifying a family
member, personal representative or any other person
that is responsible for your care, general condition
or death. If you are not present or able to agree
or object to the use or disclosure of the protected
health information, then your physician may, using
professional judgment, determine whether the disclosure
is in your best interest. In this case, only the
protected health information that is relevant to
your healthcare will be disclosed.
* As Required By Law
We may use or disclose your protected health information
to the extent that is required by law.
* For Public Health
We may disclose your protected health information
for public health activities and purposes to a public
health authority that is permitted by law to collect
or receive the information.
* For Communicable Diseases
We may disclose your protected health information,
if authorized by law, to a person who may have been
exposed to a communicable disease or may otherwise
be at risk of contracting or spreading the disease
or condition.
* For Health Oversight
We may disclose protected health information to
a health oversight agency for activities authorized
by law, such as audits, investigations, and inspections.
* In Cases of Abuse or Neglect
We may disclose your protected health information
to a public health authority that is authorized
by law to receive reports of child abuse or neglect.
In addition, we may disclose your protected health
information if we believe that you have been a victim
of abuse, neglect or domestic violence to the governmental
entity or agency authorized to receive such information.
In this case, the disclosure will be made in a manner
that is consistent with the requirements of applicable
federal and state laws.
* To The Food and Drug Administration
We may disclose your protected health information
to a person or company required by the Food and
Drug Administration to report adverse events, to
monitor product defects or problems, to report biologic
product deviations, to track products, to enable
product recalls, to make repairs or replacements,
or to conduct post-marketing surveillance, as required.
* For Legal Proceedings
We may disclose protected health information in
the course of any judicial or administrative proceeding,
in response to an order of a court or administrative
tribunal (to the extent such disclosure is expressly
authorized), in certain conditions in response to
a subpoena, discovery request or other lawful process.
* To Law Enforcement
We may also disclose protected health information,
as long as applicable legal requirements are met,
for law enforcement purposes.
* Organ and Tissue Donation
Protected health information may be used and disclosed
for cadaveric organ, eye or tissue donation purposes.
* In Cases of Criminal Activity
Consistent with applicable federal and state laws,
we may disclose your protected health information
if we believe that the use or disclosure is necessary
to prevent or lessen a serious and imminent threat
to the health or safety of a person or the public.
We may also disclose protected health information,
if it is necessary for law enforcement authorities,
to identify or apprehend an individual.
* For Military Activity and National Security
When the appropriate conditions apply, we may
use or disclose protected health information of
individuals who are Armed Forces personnel: (1)
for activities deemed necessary by appropriate military
command authorities; (2) for the purpose of a determination
by the Department of Veterans Affairs of your eligibility
for benefits; or (3) to foreign military authority
if you are a member of that foreign military service.
* For Workers’ Compensation
Your protected health information may be disclosed
as authorized to comply with workers’ compensation
laws and other similar legally-established programs.
* When an Inmate
We may use or disclose your protected health information
if you are an inmate of a correctional facility
and your physician created or received your protected
health information in the course of providing care
to you.
* Required Uses and Disclosures
Under the law, we must make disclosures about
you when required by the Secretary of the Department
of Health and Human Services to investigate or determine
our compliance with the requirements of the Privacy
Rule.
Complaints
You may complain to us or to the Secretary of Health
and Human Services if you believe your privacy rights
have been violated by us. You may file a complaint
with us by notifying our Privacy Manager of your
complaint.
Publish date: 4-1-2003 - Effective date: 4-15-2003
