Effective April 14, 2003
Revised November 01, 2012
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
We are required by applicable federal and state law to maintain the privacy of your medical information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information. We must follow the privacy practices that are described in this notice while it is in effect. This notice will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.
You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.
This notice applies to the privacy practices of Fort Wayne Orthopaedics, LLC at Jefferson Blvd., Dupont, Adams Memorial, Angola, Auburn, Lagrange, Parkview North, Rochester and Topeka. We may share your medical information and the medical information of others needed for treatment, payment or health care operations relating to our organized health care arrangement.
We may use and disclose medical information about you for treatment, payment, and health care operations. For example:
Treatment: We may use or disclose your medical information to a physician or other health care provider in order to provide treatment to you.
Payment: We may use and disclose your medical information to obtain payment for services we provide to you. We may disclose your medical information to another health care provider or entity subject to the federal Privacy Rules so they can obtain payment.
Health Care Operations: We may use and disclose your medical information in connection with our health care operations. Health care operations include:
We may disclose your medical information to another entity, which has a relationship with you and is subject to the federal Privacy Rules, for their health care operations relating to quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, or detecting or preventing health care fraud and abuse.
On Your Authorization: You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your medical information for any reason except those described in this notice.
To Your Family and Friends: We may disclose your medical information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care. We may use or disclose your name, location, and general condition or death to notify, or assist in the notification of (including identifying or locating), a person involved in your care.
Before we disclose your medical information to a person involved in your health care or payment for your health care, we will provide you with an opportunity to object to such uses or disclosures. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest.
We will also use our professional judgment and our experience with common practice to allow a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of medical information.
We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit:
We may use or disclose your medical information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.
We may use your medical information to contact you to provide appointment reminders or to provide you with information about health-related benefits and services or about treatment alternatives that may be of interest to you. We may use and disclose your health information to conduct surveys or contact you for patient surveys to improve patient care. We may disclose your medical information to a business associate to assist us in these activities.
We may use or disclose your medical information to encourage you to purchase or use a product or service by face-to-face communication or to provide you with promotional gifts.
We may use your demographic information and the dates of your health care to contact you for our fundraising purposes. We may disclose this information to a business associate or foundation to assist us in our fundraising activities. We will provide you with any fundraising materials and include with the written fundraising communication a description of how you may opt out of receiving future fundraising communications.
Access: You have the right to look at or get copies of your medical information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your medical information. You may obtain a form to request access by using the contact information listed at the end of this notice. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, we may charge you $15.00 retrieval fee which covers the first ten (10) pages copied and then it would be $0.25 for each page over ten (10) pages, actual postage costs, and $10.00 additional charge for rush requests. If you request an available alternative format, we will charge a cost-based fee for providing your medical information in that format. If you prefer, we will prepare a summary or an explanation of your medical information for a fee. We legally have up to 30 days to respond to your request. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities, since April 14, 2003. We will provide you with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your medical information, a description of the medical information we disclosed, the reason for the disclosure, and certain other information. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. We legally have up to 60 days to respond to your request. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to a requested restriction other than as expressly stated herein, but if we do, we will abide by our agreement (except in an emergency). Any agreement to additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. We will not be bound unless our agreement to do so is in writing. If you request that we restrict the disclosure of your medical information to a health plan for purposes of carrying out payment or health care operations (and not for treatment purposes), and the information you seek to restrict pertains solely to a health care item or services for which we have been paid out of pocket in full, we must comply with the requested restriction, except as otherwise required by law.
Confidential Communication: You have the right to request that we communicate with you about your medical information by alternative means or to alternative locations. You must make your request in writing. We must accommodate your request if it is reasonable, specifies the alternative means or location, and provides satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your medical information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended and the originator remains available or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information. We legally have up to 60 days to respond to your request.
Electronic Notice: If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact us using the information listed at the end of this notice to obtain this notice in written form.
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information or in response to a request you made to amend or restrict the use or disclosure of your medical information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.