Notice of Privacy Practices
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The effective date of this notice is April 14, 2003.
Uses and Disclosures of Your Health Information
Interventional Spine Medicine (ISM) will use and disclosure your health information as follows:
- 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, we may send relevant portions of your medical record to specialists to whom you are being referred or to whom your provider here may want to consult regarding your medical diagnosis or treatment.
- Payment: We will use your health information for payment. For example, your protected health information (PHI) may be disclosed to your insurance company(s) or case manager to obtain approval for a treatment or procedure.
- Health Care Operations: We will use your health information to support day-to-day activities and management of Interventional Spine Medicine. For example, providers, clinical and/or administrative staff members may assess the information in your medical record in an effort to continually improve the quality and effectiveness of the healthcare services we provide.
- Business Associates: We provide some services with business associates-independent professionals that use patient health information provided by us in order to perform these services. Examples include quality assurance consultants and transcription, copy and/or billing services. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do. We require our business associates to appropriately safeguard your information.
- Uses and Disclosures that we may make unless you object: Unless you object, health professionals, using their best judgment, 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 payment related to your care.
- Other Uses and Disclosures that we may make without your authorization:Uses and disclosure required by law, public health activities, victims of abuse, neglect or domestic violence, health oversight activities, judicial or administrative proceedings, law enforcement purposes, coroners, funeral directors medical examiners about descendents, organ donations, research purposes, health and safety, specialized government functions, workers compensation.
You have certain rights under the federal privacy standards. These include the:
Right to inspect and copy your protected health information by providing a written request to the Privacy Officer specifying your name, date of birth, what information you are requesting access to, and in what format. If you request a copy of information, we may charge a fee for the costs of copying, mailing or other supplies needed to fulfill your request.
Right to request restrictions on the use and disclosure of your protected health information for treatment, payment or healthcare operations by submitting a written request to the Privacy Officer specifying your name, date of birth, the exact restriction you are requesting, the date the restriction would be in effect (if approved), the purpose of the restriction and contact information. While we will accept requests for restrictions, we are not required to agree to the restriction.
Right to request confidential communications by asking us to communicate with you concerning your health information only in certain ways or at certain locations. For example, you may request that we only contact you at work or by mail. Any such request must be made in writing to the Privacy Officer and include your name, date of birth, current address and phone number, the specific alternative means of communication or location to communicate with you. Where possible, we will accommodate all reasonable requests.
Right to request amendment to your protected health information. If you feel your information maintained by Interventional Spine Medicine is incorrect or incomplete, you may ask us to amend the information by contacting the Privacy Officer in writing. Your request must include your name, date of birth, what amendment is being requested and the reason for the requested amendment. While we will accept requests for amendment we are not required to agree to the amendment.
Right to an accounting of disclosures for disclosures made for reasons other than for treatment, payment or health care operations. Requests for accounting may be made in writing or verbally and must include your name, date of birth, the request for accounting, and the period to be accounted for. Requests can be for periods up to six years prior to the request but may not include dates prior to April 14, 2003. We may charge a fee for the costs of copying, mailing or other supplies needed to fulfill your request.
Right to obtain a paper copy of this notice upon oral or written request.
Interventional Spine Medicine’s Duties
Interventional Spine Medicine is required by the Federal Privacy Rules to do the following:
- Make sure your protected health information is kept private.
- Provide you this notice of our legal duties and privacy practices related to the use and disclosure of your PHI.
- Follow the terms of the notice currently in effect.
- Communicate any changes in the notice to you.
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal or state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised copy on your next office visit. Complaints
If you believe these privacy rights have been violated you may file a written complaint within 180 days to our Privacy Officer or the Department of Health and Human Services. No retaliation will occur against you for filing a complaint.
For More Information or to Report a Problem
Interventional Spine Medicine
944 Calef Highway
Barrington, NH 03825