HIPAA Notice of Privacy Practices
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.
I. Our Commitment
We are committed to protecting the personal information entrusted to us by our patients. The trust you place in us when you share your personal information is a responsibility we take very seriously and is the cornerstone of how we conduct our business.
The Health Insurance Portability and Accountability Act (HIPAA) provides us with guidelines and standards to follow when we use or disclose your Protected Health Information (PHI). This new law also gives you, our patient, numerous rights regarding your ability to see, inspect, and copy your PHI. Because our commitment to privacy means complying with all privacy laws, we are providing you this notice outlining our privacy practices. The following information is intended to help you understand what we can and cannot do with your PHI and what your rights are under HIPAA.
II. Our Use and Disclosure of Your PHI
HIPAA allows us to use and disclose your PHI for treatment, payment, and medical care operations without
asking your permission. For instance, we may disclose information to a medical provider to assist the provider in properly treating you or a dependent (Treatment). We may disclose certain information to the medical provider in order to properly pay a claim or to your employer in order to collect the correct premium amount (Payment). We may disclose your information in order to help us make the correct underwriting decision or to determine your eligibility (Operations).
Other examples of possible disclosures for purposes of medical care operations include:
• Underwriting our risk and determining rates and premiums for your medical plan;
• Determining your eligibility for benefits;
• Reviewing the competence and qualifications of medical care or other providers;
• Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance;
• Business planning and development;
• Business management and general administrative duties such as cost-management, customer service, and resolution of internal grievances;
• Other administrative purposes.
We can also make disclosures under the following circumstances without your permission:
• As required by law, including response to court and administrative orders, or to report information about suspected criminal activity;
• To report abuse, neglect, or domestic violence;
• To authorities that monitor our compliance with these privacy requirements;
• To coroners, medical examiners, and funeral directors;
• For research and public health activities, such as disease and vital statistic reporting;
• To avert a serious threat to health or safety;
• To the military, certain federal officials for national security activities, and to correctional institutions;
• To the entity sponsoring your medical plan but only for purposes of enrollment, disenrollment, and eligibility. We also are allowed to give the plan sponsor summary information when necessary to help make decisions regarding changes to the plan;
• To a spouse, family member, or other personal representative if they can show they are assisting in your care or payment of your care and then, without an authorization, only basic information about the status or payment of a claim.
III. Your Individual Rights
You have the following rights with regard to your Protected Health Information:
• To Restrict our Use or Disclosure. You have the right to ask us to limit our use of disclosure of your PHI. While we will consider your request, we are not legally required to agree to the additional restrictions. If we do agree to all or part of your request, we will inform you in writing. We cannot agree to limit any use and disclosure of your PHI if the use or disclosure is required by law.
• To Access your PHI. You have the right to view and/or copy your PHI at any time by contacting us. If you want copies of your PHI, or want your PHI in a special format, we may charge you a fee. You have a right to choose
what portions of your PHI you want copied and to have prior notice of copying costs. If for some reason we deny your request for access to your PHI, we will provide a written explanation of why your request was denied and explain how you can appeal the denial.
• To Amend your PHI. You have the right to amend your PHI, if you believe it is incomplete or inaccurate. Your request must be in writing, with an explanation of why you feel the information should be amended. If we approve your request to amend your PHI, we will make reasonable efforts to inform others, including people you name, about the amendment to your PHI. We may deny your request for various reasons, for example, if we
determine that the information is correct and complete, or if we did not create the information. If we deny your request, we will provide you a written explanation of our decision. We also will explain your rights regarding having your request and our response included with all future disclosures of your PHI.
• To Obtain an Accounting of our Disclosures. You have the right to receive a listing from us of all instances in which we or our business associates have disclosed your PHI for purposes other than treatment, payment, health care operations, or as authorized by you. This list will include only those disclosures made since April 14, 2003 and will only go back six years. The accounting will tell you the date we made the disclosure, the name of
the person or entity to which the disclosure was made, a description of the PHI that was disclosed and the reason for the disclosure. There may be a charge for accounting disclosures if requested more than once a year.
• To Receive Notice. You are entitled to receive a copy of this notice that outlines our HIPAA privacy practices and the terms of this notice at any time. We will not make any material changes to our privacy practices without first sending you a revised notice. If you receive this notice on our website or by electronic mail, you may request a paper copy.
IV. Who to Contact for Questions and Complaints
If you want more information about our privacy practices, wish to exercise any of your rights with regard to your PHI, or have any questions about the information in this notice; please use the contact information below. If you believe we may have violated your privacy rights, or if you disagree with a decision that we made in connection with your PHI, you may file a complaint using the contact information below. You may also submit a written complaint to the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights, 200 Independence Ave SW, Washington D.C. 20201. We fully support your right to the privacy of your PHI, and will not retaliate in any way if you choose to file a complaint.
V. Effective Date of This Notice: April 14, 2003
Est. 1996
Oklahoma City
Azhar Therapy & Fitness
3410 NW 135th Street
Oklahoma City, OK 73120
(405) 752-7377 phone
(405) 752-7387 fax
© 2009 Azhar Therapy & Fitness, Inc
