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The Breast Health Clinic
Notice of Privacy Practices for Protected Health Information

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!

Your Privacy is very important to us. We understand that keeping your
confidential medical information private is important to you.

This office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations.   Protected Health Information is the information we create and obtain in providing our services to you and billing for those services.

Examples of uses of your health information for treatment purposes are:

•  A nurse obtains treatment information about you and records it in a health record.
•  During the course of your treatment, the physician determines he will need to consult with another specialist in the area.   He will share the information with such specialist and obtain his input.

Examples of uses of your health information for payment purposes:

•  We submit requests for payment to your health insurance company.   The health insurance company (or other business associate helping us obtain payment) requests information from us regarding medical care given.   We will provide information to them about you and the care given.  

Examples of uses of your health information for health care operations:

•  We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance.   We will share information about you with such insurers or other business associates as necessary to obtain these services.

To preserve your privacy we pledge to:

•  Collect only the information we need to provide you with the best possible Medical Care.

•  Protect against unauthorized access to your information.

•  Refuse to disclose medical information to third parties for marketing purposes.

•  Require anybody involved in your care to protect your medical information in accordance with strict privacy standards.

•  Maintain physical, electronic and procedural safeguards that meet state and federal regulations.

•  Limit access to your information to people who need the information in order to perform their job responsibilities.

The health and billing records we maintain are the physical property of our office.   The information in it, however, belongs to you.   You have a right to:

•  Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office - we are not required to grant the request but we will comply with any request granted;

•  Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our office;

•  Request that you be allowed to inspect and copy your health record and billing record - you may exercise this right by delivering the request in writing to our office.

•  Appeal a denial of access to your Protected Health Information;

•  Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;

•  File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your Protected Health Information;

•  Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office;

•  Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights, please contact Piera at our office (325 North Jeff Davis Drive, Fayetteville, GA 30214) in person or writing during normal hours.  

You have the right to review this Notice before signing the consent authorizing use and disclosure of your Protected Health Information for treatment, payment, and health care operations purposes.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the Protected Health Information we maintain.   If your information practices change, we will amend our Notice.   You are entitled to obtain a revised copy of the Notice from our office.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Piera, the Office Manager at 770-461-1337.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Piera.   You may also file a complaint by mailing it to the Secretary of Health and Human Services at The U.S. Department of Health and Human Services, Washington, D.C.

•  We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office.

•  We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Other Disclosures and Uses

Notification - Unless you object, we may disclose your Protected Health Information to notify, or assist in notifying a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication - Unless otherwise advised by you in writing we will remind you of your appointment and leave a message on your answering machine.

We maintain a sign-in sheet and, unless notified by you in writing, we expect you to sign your name upon arrival in our office.

We will provide you with monthly statements of your account until your account is paid in full.   If you do not wish to receive monthly statements you may inform us in writing.   In this case, the account needs to be paid in full at the time of the request.

Communication with Family - Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

Research - We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your Protected Health Information.

Workers Compensation - If you are seeking compensation through Workers Compensation, we may disclose your Protected Health Information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health - As required by law, we may disclose your Protected Health Information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Correctional Institutions - If you are an inmate of a correctional institution, we may disclose to the institution, or its agents the Protected Health Information necessary for your health and the health and safety of other individuals.

Law Enforcement - We may disclose your Protected Health Information for law enforcement purposes as required by law, such as when required by court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight - Federal law allows us to release your Protected Health Information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings - We may disclose your Protected Health Information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Defense of Medical Professional Liability Claims Asserted by Patients . We may disclose Protected Health Information in the event a liability claim is lodged against our practice.

For Specialized Governmental Functions - We may disclose your Protected Health Information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Website - If we maintain a website that provides information about our entity, this Notice will be on the website.


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