Notice of PRIVACY Practices

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices is for Alexius M. Bishop, M.D., P.S.C., and any affiliated entities of this Practice which provide health care services to your child and are committed to protecting the privacy and security of your child’s protected health information (“PHI”).  Protected health information is information about your child, including demographic information (name and address, for example), that may identify your child and that relates to your child’s past, present or future physical or mental health information and related health care services. While your child is a patient of the Practice, we create records of the health care services that have been provided to your child; they include PHI.  We need these records to provide your child with quality health care services and to comply with legal requirements.

We are required by law to maintain the privacy of your child’s protected health information and to provide you with this notice regarding our legal duties and our privacy practices with respect to your child’s protected health information so that you will understand your rights, our legal duties, and how we may use or disclose protected health information about your child.

A.        HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU.

The following categories describe the ways that we use and disclose protected health information about your child.  Not every use or disclosure in a category will be listed.  However, all of the ways we use and disclose protected health information about your child will fall into one of these categories.

1.    For Treatment:  We may use or disclose protected health information about your child to provide your child with health care services.  We may disclose protected health information about your child to other health care professionals and health care providers who need to know about the health care services we provide in order for them to treat your child.

2.    For Payment:  We may use or disclose protected health information about your child so that the health care services your child receives through the Practice may be billed to you, an insurance company, or a third party.  For example, if you have health insurance we will disclose information to your health plan about services provided to your child.  We may also tell your health plan about a health care service your child is going to receive to obtain prior approval or to determine whether your plan will cover the health care service.

3.    For Health Care Operations:  We may use or disclose protected health information about your child for our health care operations.  For example, we may use health care information about your child to assess the health care services provided to your child and the outcomes from that pharmacy service in an effort to continually improve the quality and effectiveness of the pharmacy services we provide.  We may also use protected health information about our patients to decide what additional services we should offer.

4.    Other Uses and Disclosures of Protected Health Information About Your Child:

Business Associates:  Some services are provided through contracts with business associates.  Examples of business associates could include attorneys, consultants, or a copy service used when making copies of your child’s health record.  When we contract for these services, we will disclose information to these business associates so that they can perform their jobs. To protect the information about your child, however, we require the business associate to appropriately safeguard the information.

Individuals Involved in Your Health Care Services or Payment for Your Health Care Services:  We may disclose protected health information about you to a family member, a close personal friend, or any other person identified by you.  We will disclose only the information that is directly relevant to that individual’s involvement with your health care services or with the payment for your health care services.  You have the right to object to these disclosures to the extent that your objection does not interfere with the ability to respond to emergency circumstances.

Required by Law:  We may use or disclose protected health information about your child as required by state or federal law, but only to authorized persons, and only to the extent necessary to meet the requirements of those laws.

Public Health Activities:  We may disclose protected health information about your child to a public health authority that is authorized to receive such information for public health purposes, including:

  • Prevention or control of disease, injury or disability;
  • Reporting births and deaths;
  • Reporting child abuse or neglect;
  • Reporting reactions to medications or problems with products;
  • Notifying people of recalls of products;\
  • Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease.

Abuse, Neglect, or Domestic Violence:  We may disclose information about your child to the appropriate authorities if we believe that your child has been the victim of abuse, neglect, or domestic violence.  We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities:  We may disclose protected health information about your child to a health oversight agency for activities authorized by law.  These oversight activities may include audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.  For example, we may use or disclose protected health information for purposes of notifying the Food and Drug Administration (FDA) of adverse events with respect to products and product recalls, or post-marketing surveillance information to enable product recalls, repairs or replacements.

Judicial or Administrative Proceedings:  We may disclose protected health information about your child in response to a court or administrative order.  We may also disclose protected health information about your child in response to a HIPAA-compliant subpoena or court order, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested, to the extent required by law.

Law Enforcement:  We may disclose protected health information about your child when requested by law enforcement official:

  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About your child, if your child is the victim of a crime and, under certain limited circumstances, we are unable to obtain your agreement;
  • About a death we believe may be the result of criminal conduct;\
  • About criminal conduct regarding the pharmacy or pharmacy services provided; or
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

 

Coroners, Medical Examiners and Funeral Directors:  We may disclose protected health information about your child to a coroner or medical examiner.  This may be necessary to identify a deceased person or determine the cause of death.  We may also disclose protected health information to funeral directors as necessary to carry out their duties.

Organ and Tissue Donation:  If your child is an organ or tissue donor, we may disclose protected health information about your child to organizations that handle organ procurement to facilitate donation and transplantation.

Research:  We may disclose protected health information about your child to researchers when we have documentation that the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of the health information.

To Avert a Serious Threat to Health or Safety:  We may disclose protected health information about your child to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Specialized Government Functions:  We may disclose protected health information about your child to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.  If your child is a member of the armed forces, we may disclose protected health information about your child as required by military authorities.  We may also disclose protected health information about foreign military personnel to the appropriate foreign military authority.  If your child is an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose protected health information about your child to the correctional institution or law enforcement official.  This disclosure would be necessary (1) for the institution to provide your child with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Workers' Compensation:  We may disclose protected health information about your child for workers' compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

Benefits and Services:  We may use or disclose protected health information about your child to tell you about possible health care options or alternatives that may be of interest to you, or to tell you about health benefits or services that may be of interest to you.  For example, we may use information about your child to provide prescription refill reminders to you.

Electronic Storage and Transmission:  We may record and transmit your health information electronically.  Health information may also be shared electronically through local, regional, state and national health information networks.

Data Breach Notification Purposes: We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information. We may send notice directly to you and/or the Department of Health.

Additional Restrictions on Use and Disclosure: Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about your child. "Highly confidential information" may include confidential information under Federal laws governing alcohol and drug abuse information and genetic information as well as state laws that often protect the following types of information:

  • HIV/AIDS;
  • Mental health;
  • Genetic tests;
  • Alcohol and drug abuse;
  • Sexually transmitted diseases and reproductive health information; and
  • Child or adult abuse or neglect, including sexual assault.

Marketing:  We must receive your authorization for any use or disclosure of protected health information for marketing, except if the communication is in the form of a face-to-face communication made to you personally; or a promotional gift of nominal value provided by us. It is not considered marketing to send you information related to your child’s individual treatment, case management, care coordination or to direct or recommend alternative treatment, therapies, health care providers or settings of care. These may be sent without written permission. If the marketing is to result in direct or indirect payment to us by a third party, we will state this on the authorization.

Sale of PHI:  We must receive your authorization for any disclosure of your PHI which is a sale of PHI.  Such authorization will state that the disclosure will result in remuneration to the Practice.

Confidentiality of Psychotherapy Notes: We must receive your authorization for any use or disclosure of psychotherapy notes, except: for use by the originator of the psychotherapy notes for treatment or health oversight activities; for use or disclosure by the Practice for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; for use or disclosure by the Practice to defend itself in a legal action or other proceeding brought by you; to the extent required to investigate or determine the Practice’s compliance with the HIPAA regulations; to the extent that this use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law; for health oversight activities with respect to the oversight of the originator of the psychotherapy notes; for disclosure to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law; or if disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.

B.        YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOUR CHILD.

Although your child’s health record is our property, the information belongs to you (or, in some instances, to your child).  You have the following rights regarding your child’s protected health information (IMPORTANT: YOUR RIGHTS DESCRIBED BELOW MAY NOT APPLY IN CERTAIN CIRUMSTANCES. PLEASE READ “D,” BELOW FOR THOSE LIMITS):

Right to Request Restrictions:  You have the right to request a restriction or limitation on the protected health information we use or disclose about your child.  For example, you may request that we not allow a certain family member to know what medications your child is prescribed.  You have the right to require restrictions on disclosure of your protected health information to a health plan where you paid out of pocket, in full, for items or services, and we are required to honor this request.

Otherwise, we are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide your child emergency treatment.

You must submit your request in writing to us.  In your request, you must tell us (1) what information you want to limit; and (2) to whom you want the limits to apply.

Right to Request Alternate Communications:  You have the right to request that we communicate with you in a confidential manner or at a specific location.  For example, you may ask that we only contact you via mail at a post office box.  You must submit your request in writing to us.  Your request must specify how or where you wish to be contacted.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.

Right to Inspect and Copy:  With some limited exceptions, you have the right to review and copy your child’s protected health information.  You must submit your request in writing to our Chief Privacy Officer.  We may charge a fee for the costs of copying, mailing or other supplies associated with your request.  In addition, you have a right to access your child’s protected health information in electronic format upon request, where it is available.

Right to Amend:  If you feel that protected health information in your child’s record is incorrect or incomplete, you may ask us to amend the information.  You have this right for as long as the information is kept by or for us.  You must submit your request in writing to us.  In addition, you must provide a reason for your request.

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

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the protected health information kept by or for us; or
  • Is accurate and complete.

If your request for an amendment is denied, and you disagree with the reason for the denial, you may file a statement of disagreement in your record.

Right to an Accounting of Disclosures:  You have the right to request an "accounting of disclosures".  This is a list of certain disclosures we made of your protected health information, other than those made for purposes such as treatment, payment, or health care operations.

You must submit your request in writing to our Chief Privacy Officer.  Your request must state a time period which may not be longer than six years from the date the request is submitted and may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (for example, on paper or electronically).  The first list you request within a 12 month period will be free.  For additional lists, we may charge you for the costs of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to a Paper Copy of This Notice:  You have the right to a paper copy of this notice even if you have agreed to receive the notice electronically.  You may ask us to give you a copy of this notice at any time by contacting us at the location described below under “Contacting Us.”  You may also obtain a copy of this Notice on our website.

C.        OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION ABOUT YOUR CHILD.

Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your written authorization.  If you provide us authorization to use or disclose protected health information about your child, you may revoke that authorization, in writing, at any time.  If you revoke your authorization, we will no longer use or disclose protected health information about your child for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to your child.

D. SPECIAL LIMITS ON YOUR RIGHT TO LEARN ABOUT HEALTH CARE SERVICES PROVIDED TO YOUR CHILD.

Abuse, Neglect and Endangerment Situations: We may elect not to disclose information about health care services we provide to your child, or information about who we may have disclosed information about your child’s condition, if:

(1) We have a reasonable belief that:

(A) Your child has been or may be subjected to domestic violence, abuse, or neglect by you; or

(B) Disclosing information to you could endanger your child; and

(2) In the exercise of our health care providers’ professional judgment, we decide that it is not in the best interest of your child to disclose that information.

Child Has the Right to Make Health Care Decisions: We are not permitted to disclose information about health care services we provide to your child, or information about who we may have disclosed information about your child’s condition, if:

(1) Your child qualifies as an adult or emancipated minor, unless your child designates you as your child’s personal representative;

(2) Your child is not an adult or emancipated minor, but --

(A) Your child consents to our providing health care service; no other consent to such health care service is required by law, regardless of whether the consent of another person has also been obtained; and the minor has not requested that you should be treated as your child’s the personal representative; or

(B) Your child may lawfully obtain a health care service from us without the consent of a parent, guardian, or other person acting in loco parentis, and your child, a court, or another person authorized by law consents to our providing the health care service; or

(C) A parent, guardian, or other person acting in loco parentis of or to your child approves an agreement of confidentiality between us and your child with respect to the health care service.

Local Law Requires or Permits Us to Restrict Access to Health Care Information About Your Child: We are not permitted to disclose information about health care services we provide to your child, or information about who we may have disclosed information about your child’s condition, if:

(1) ) State or other law prohibits us from making those disclosures; or

(C) In the exercise of our health care providers’ professional judgment, we decide that it is not in the best interest of your child to disclose that information to you and no State or other law guarantees you the right to that information.

E.        CHANGES TO THIS NOTICE.

We are required to abide by the terms of this notice, as it may be updated from time to time.  We reserve the right to change this notice and to make the changed notice effective for information we already have about your child as well as any information we receive in the future.  If we change this notice, the new notice will specify the effective date for the changed notice, and we will distribute the new notice to all patients on service at the time of the change and/or to the extent required by law.  Copies of the current notice can be obtained by contacting us at the location described below under “Contacting Us” or by visiting our website.

F.         COMPLAINTS.

If you believe your child’s privacy rights have been violated, you may file a complaint with us at the location described below under “Contacting Us” or with the Secretary of the Department of Health and Human Services.  All complaints must be submitted in writing.  You will not be retaliated against for filing a complaint.

F.         BREACH NOTIFICATION.

In the event of any breach of unsecured PHI, we shall fully comply with the HIPAA/HITECH breach notification requirements, which will include notification to you of any impact that breach may have had on you, your child and/or your other family member(s) and actions we undertook to minimize any impact the breach may or could have on you or your child.

G.        CONTACTING US.

To request additional copies of this notice or to receive more information about our privacy practices or your rights, please contact us at this address:

Alexius M. Bishop, M.D., P.S.C.

45 Cavalier Boulevard.

Florence, KY 41042

Attention: HIPAA Privacy Request

H.        EFFECTIVE DATE.

The effective date of this Notice Is September 1,  2013.

I.          ACKNOWLEDGMENT.  

I acknowledge that I have been provided a copy of the Practice Notice of Privacy Practices.

________________________________

 

_________________________________

Individual

(Print Name)

OR

Individual’s Representative

(Print Name and Relationship to Individual)

     

________________________________

 

_________________________________

Individual’s Signature

  OR

Individual’s Representative - Signature

     
     

______________________________

Date

For Practice Use

If an acknowledgment signature could not be obtained, document our good faith effort to obtain the acknowledgment signature and the reason why it was not obtained:

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

By (Practice Representative):  _____________________________

                                        Date:  _________________

 
Drs. Bishop, Adams, Poon, Berger and Young
45 Cavalier Boulevard
Florence, KY 41042
Phone:          (859) 371-7400
After Hours: 1-866-985-5663
Fax:              (859) 371-8472
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