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Notice of Privacy Practices
Date of Last Revision: April 14, 2003
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.
THIS NOTICE APPLIES TO ALL OF THE RECORDS OF YOUR
CARE GENERATED BY MILab, ("COMPANY") WHETHER MADE
BY THE COMPANY OR AN ASSOCIATED FACILITY.
Uses and Disclosures Treatment. Your health
information may be used by staff members or disclosed to other health care
professionals for the purpose of evaluating your health, diagnosing
medical conditions, and providing treatment. For example, results of
laboratory tests and procedures will be available in your medical record
to all health professionals who may provide treatment or who may be
consulted by staff members.
Payment. Your health
information may be used to seek payment from your health plan and from
other sources such credit card companies that you may use to pay for
services. For example, your health plan may request and receive
information on dates of service, the services provided, and the medical
condition being treated.
Health care operations. Your
health information may be used as necessary to support the day-to-day
activities and management of our Company. For example, information on the
services you received may be used to support budgeting and financial
reporting, and activities to evaluate and promote quality.
Law
enforcement. Your health information may be disclosed to law
enforcement agencies to support government audits and inspections, to
facilitate law-enforcement investigations, and to comply with government
mandated reporting.
Public health reporting. Your health
information may be disclosed to public health agencies as required by law.
For example, we are required to report certain communicable diseases to
the state's public health department.
Other uses and disclosures
require your authorization. Disclosure of your health information or its
use for any purpose other than those listed above requires your specific
written authorization. If you change your mind after authorizing a use or
disclosure of your information you may submit a written revocation of the
authorization. However, your decision to revoke the authorization will not
affect or undo any use or disclosure of information that occurred before
you notified us of your decision to revoke your
authorization.
Additional Uses of
Information Appointment reminders. Your health information
may be used by our staff to send you appointment
reminders.
Information about treatments. Your health
information may be used to send you information that you may find
interesting on the treatment and management of your medical condition. We
may also send you information describing other health-related products and
services that we believe may interest you.
Fund raising.
Unless you request us not to, we may use your name and address to support
our fund-raising efforts, if any. If you do not want to participate in
fund-raising efforts, please check off the following box.
[ ]
Please do not use my information for fund raising
purposes.
Individual Rights You have certain rights under
the federal privacy standards. These include the following and are
explained in greater detail in the PATIENT RIGHTS section of this
notice:
- the right to request restrictions on the use and disclosure of your
protected health information
- the right to receive confidential communications concerning your
medical condition
- the right to inspect and copy your protected health information
- the right to amend or submit corrections to your protected health
information
- the right to receive an accounting of how and to whom your protected
health information has been disclosed
- the right to receive a printed copy of this notice
Duties of the Company We are required by law to maintain the
privacy of your protected health information and to provide you with this
notice of privacy practices. We also are required to abide by the privacy
policies and practices that are outlined in this notice.
Right
to Revise Privacy Practices As permitted by law, we reserve the
right to amend or modify our privacy policies and practices. Changes in
our policies and practices may be required by changes in federal and state
laws and regulations. Upon request, we will provide you with the most
recently revised notice on any office visit. The revised policies and
practices will be applied to all protected health information we
maintain.
Requests to Inspect Protected Health Information
You may generally inspect or copy the protected health information that we
maintain. As permitted by federal regulation, we require that requests to
inspect or copy protected health information be submitted in writing. You
may obtain a form to request access to your records by contacting our
receptionist or privacy officer. Your request will be reviewed and will
generally be approved unless there are legal or medical reasons to deny
the request.
Complaints If you would like to submit a
comment or complaint about our privacy practices, you can do so by sending
a letter outlining your concerns to:
Vida Acosta, Privacy
Officer MILab
If you believe that your privacy rights
have been violated, you should call the matter to our attention by sending
a letter describing the cause of your concern to the same address. You
will not be penalized or otherwise retaliated against for filing a
complaint.
Contact Person
The name and address of the
person you can contact for further information concerning our privacy
practices is as noted above. You may call our Privacy Officer at
1-877-737-7652.
Effective Date This Notice is effective
on or after April 14, 2003.
PATIENT RIGHTS
THIS
SECTION DESCRIBES YOUR RIGHTS AND THE OBLIGATIONS OF THIS COMPANY
REGARDING THE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION.
You have the following rights regarding medical information we maintain
about you:
Right to Inspect and Copy You have the right
to inspect and copy medical information that may be used to make decisions
about your care. This includes your own medical and billing records, but
does not include psychotherapy notes. Upon proof of an appropriate legal
relationship, records of others related to you or under your care
(guardian or custodial) may also be disclosed. To inspect and copy your
medical record, you must submit your request in writing to our Privacy
Officer. If you request a copy of the information, we may charge a fee for
the costs of copying, mailing or other supplies (tapes, disks, etc.)
associated with your request. We may deny your request to inspect and copy
in certain very limited circumstances. If you are denied access to medical
information, you may request that our denial be reviewed. Another licensed
health care professional chosen by the Company will review your request
and the denial. The person conducting the review will not be the person
who denied your request. We will comply with the outcome and
recommendations from that review.
Right to Amend If you
feel that the medical information we have about you in your record is
incorrect or incomplete, then you may ask us to amend the information by
following the procedure below.
You have the right to request an
amendment for as long as the Company maintains your medical
record.
To request an amendment, your request must be submitted in
writing, along with your intended amendment and a reason that supports
your request to amend. The amendment must be dated and signed by you and
notarized.
We may deny your request for an amendment if it is not
in writing or 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 medical information kept by or for the Company;
- Is not part of the information which you would be permitted to
inspect and copy; or
- Is inaccurate and incomplete.
Right to an Accounting of Disclosures You have the right to
request an "accounting of disclosures." This is a list of the disclosures
we made of medical information about you, to others. To request this list,
you must submit your request in writing. Your request must state a time
period not longer than six (6) years back and may not include dates before
April 14, 2003 (or the actual implementation date of the HIPAA Privacy
Regulations). Your request should indicate in what form you want the list
(for example, on paper or electronically). 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 Request
Restrictions You have the right to request a restriction or limitation
on the medical information 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 care or the payment for your care (a family member or
friend). For example, you could ask that we not use or disclose
information about a particular treatment you received.
We are
not required to agree to your request and we may not be able to comply
with your request. If we do agree, we will comply with your request
except that we shall not comply, even with a written request, if the
information is excepted from the consent requirement or we are otherwise
required to disclose the information by law.
To request
restrictions, you must make your request in writing and your request must
indicate:
- what information you want to limit;
- whether you want to limit our use, disclosure or both; and
- to whom you want the limits to apply, (e.g., disclosures to your
children, parents, spouse, etc.)
Right to Request Confidential Communications You have the
right to request that we communicate with you about medical matters in a
certain way or at a certain location. For example, you can ask that we
only contact you at work or by mail, that we not leave voice mail or
e-mail, or the like.
To request confidential communications, you
must make your request in writing. We will not ask you the reason for your
request. We will accommodate all reasonable requests. Your request
must specify how or where you wish us to contact you.
Right to a
Paper Copy of This Notice You have the right to a paper copy of
this notice. You may ask us to give you a copy of this notice at any time.
Even if you have agreed to receive this notice electronically, you are
still entitled to a paper copy of this notice.
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