NOTICE OF INFORMATION PRACTICES
301 Wolverine Trail, Suite 100
Smyrna, TN 37167
This notice describes how information about you may be used and disclosed and how you can get access to this information.
Please review carefully.
Patient Health Information
Under Federal Law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment and related medical information. Your health information also includes payment, billing and insurance information.
How We Use Your Patient Health Information
We use health information about you for treatment, to obtain payment and for health care operations, including administrative purposes and evaluation of the quality of care that you receive. Before we can use the information for these purposes, we must obtain your written consent. That consent is included on a form that you have been asked to sign.
This notice gives examples of how we will use or disclose your health information for treatment, payment and health care operations. The notice describes circumstances when we may have to use or disclose the information even without your consent.
Examples of Treatment, Payment & Health Care Operations
Treatment: We will use and disclose your health information to provide you with medical treatment or services. For example: nurses, physicians and other members of your treatment team will record information in your records and use it to determine the most appropriate course of care. We may also disclose the information to other health care providers who are participating in your treatment, to pharmacists who are filling your prescriptions and to family members who are assisting with your care.
Payment: We will use and disclose your health information for payment purposes. For example: we may need to obtain authorization from your insurance company before providing certain types of treatment. We will submit bills and maintain records of payments from your health plan.
Health Care Operations: We will use and disclose your health information to conduct our standard internal operations, including proper administration or records, evaluation of the quality of treatment and to assess the care and outcome of your case and others like it.
We may use your information to contact you with appointment reminders. We will also contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Other Uses & Disclosures
We may use or disclose identifiable health information about your for other reasons, even without your consent. Subject to certain requirements, we are permitted to give out health information without your consent for the following purposes:
- Required By Law: We may be required by law to report gunshot wounds, suspected abuse or neglect, or similar injuries or events.
- Public Health Activities: As required by law, we may disclose vital statistics, diseases, information related to recalls of dangerous products to public health authorities, and similar information.
- Health Oversight: We may be required to disclose information to assist in investigations and audits, eligibility for government programs, and similar activities.
- Judicial and Administrative Proceedings: We may disclose information in response to an appropriate subpoena or court order.
- Law Enforcement Pupose: Subject to certain restrictions. We may disclose information required by law enforcement officials.
- Death: We may report information regarding deaths to coroners, medical examiners and funeral directors.
- Serious Threat to Health or Safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
- Military & Veterans: If you are a member of the Armed Forces, we may release information as required by military command authorities.
- Research: We may use or disclose information for approved medical research.
- Worker's Compensation: We may release information about your for worker's compensation or similar programs providing benefits for work related injuries or illness.
In any other situations, we will ask your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.
You have the following rights with regard to your health information. Please contact the person listed on this form for exercising these rights.
Request Restricitons: You may request restrictions on certain uses and disclosures of your health information. We are not required to agree with such restrictions, but if we do agree, we must abide by those restrictions.
Confidential Communications: You may ask us to communicate with you confidentially by, for example, sending notices to a special address or not using postcards to remind you of appointments.
Inspect & Obtain Copies: In most cases, you have the right to look at or get a copy of your health information. There may be a small charge for copies.
Amend Information: If you believe that information in your records is incorrect, or if important information is missing, you have the right to request that we correct the existing information or add the missing information.
Our Legal Duty
We are required by law to protect and maintain the privacy of your health information, to provide this notice about our legal duties and privacy practices regarding protected health information, and to abide by the terms of the notice currently in effect.
Changes in Privacy Practices
We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice. You can also request a copy of our notice at anytime. For more information about our privacy practices, contact the person listed below.
If you are concerned that we have violated your privacy rights, or if you disagree with the decision made about your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person below will provide you with the appropriate address upon request. You will nto be penalized in any way for filing a complaint.
If you have any questions, request, or complaints, please contact:
301 Wolverine Trail, Suite 100
Smyrna, TN 37167
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