Notice of Privacy Practices

You may fill out and submit this form on our Web site! Or, if you have concerns about providing information via the internet, print this form prior to an appointment. Then bring it with you to your first visit to save time when you arrive.

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.

Our office is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about the privacy practices at our office, please contact:

Thad Beagle, Compliance/Privacy Officer
870-698-1846
501 Virginia Drive
Batesville, AR 72501

Effective Date of This Notice: April 15, 2003

I. How Our Office May Use or Disclose Your Health Information

Our office collects health information from you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of our office, but the information in the medical record belongs to you. Our office protects the privacy of your health information. The law permits our office to use or disclose your health information for the following purposes:

1. Treatment
Our practice may use your PHI to treat you. For example, we may ask you to have diagnostic (such as an X-ray or MRI) of laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the employees who work for our practice - including, but not limited to, our doctors, nurses, and business office staff - may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children, or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.

2. Payment
Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. As an example, we may contact your health insurer to certify that you are eligible for benefits (and for what array of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members and/or to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

3. Regular health care operations
Our practice may use and disclose your PHI to operate our business. Some of the ways in which we may use and disclose your information for our operations is to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations.

4. Information provided to you

5. Notification and communication with family
We may disclose your health information to notify or assist in notifying a family member, your personal representative, or another person responsible for your care about your location, your general condition, or, in the event of your death. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

6. Required by law.
As required by law, we may use and disclose your health information.

7. Public health
As required by law, we may disclose your health information to public health authorities for purposes related to: prevention or controlling disease; injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.

8. Health oversight activities
We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure, and other proceedings.

9. Judicial and administrative proceedings
We may disclose your health information in the course of any administrative or judicial proceeding.

10. Law enforcement
We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.

11. Deceased person information
We may disclose your health information to coroners, medical examiners, and funeral directors.

12. Organ donation
We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissue.

13. Research
We may disclose your health information to researchers conducting that has been approved by an Institutional Review Board or (this organization’s) privacy board.

14. Public safety
We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

15. Worker’s compensation
We may disclose your health information as necessary to comply with worker’s compensation laws.

16. Marketing
We may contact you to provide appointment reminders or to give you information about other treatments or health-related benefits and services that may be of interest to you.

17. Change of ownership
In the event that the practice is sold or merged with another organization, your health information/record will become the property of a new owner.

18. Specialized government functions.
We may disclose your health information for military, national security, and prisoner purposes.

II. When Our Office May Not Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, our office will not use or disclose your health information without your written authorization. If you do authorize our office to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

III. Your Health Information Rights

1. You have the right to request restrictions on certain uses and disclosures of your health information. Our office is not required to agree to the restrictions that you requested.

2. You have the right to receive your health information through a reasonable alternative means or at an alternative location. You may request this in writing. You may see Thad Beagle, Compliance/Privacy Officer, 870-698-1846, Batesville Surgery Specialties Clinic, 501 Virginia Drive, Batesville, AR 72501, to obtain the form required.

3. You have the right to inspect and copy your health information. You will not be charged for one copy per year. Subsequent copies are $15.00.

4. You have a right to request that our office amend your health information that is incorrect or incomplete. Our office is not required to change your health information and will provide you with information about our office’s denial and how you can disagree with the denial.

5. You have a right to receive an accounting of disclosures of your health information made by our office, except that our office does not have to account for the disclosures described in parts I (treatment), 2 (payment), 3 (health care operations), 4 (information provided by you), and 18 (certain government functions) of section I of this Notice of Privacy Practices.

6. You have a right to a paper copy of this Notice of Privacy Practices.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of those rights, contact our Compliance/Privacy officer:

Thad Beagle, Compliance/Privacy Officer
870-698-1846
Batesville Surgery Specialties Clinic
501 Virginia Drive
Batesville, AR 72501

IV. Changes to this Notice of Privacy Practices

Our office reserves the right to amend this Notice of Privacy Practices at any time in the future, and to make the new provisions effective for all information that it maintains, including information that was created or received prior to the date of such amendment. Until such amendment is made, our office is required by law to comply with this Notice. If our office revises this Notice of Privacy Practices a copy of the new Notice of Privacy Practices will be mailed to your last address we have in our records.

V. Complaints

Complaints about this Notice of Privacy Practices or how our office handles your health information should be directed to:

Thad Beagle, Compliance/Privacy Officer
870-698-1846
Batesville Surgery Specialties Clinic
501 Virginia Drive
Batesville, AR 72501

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Department of Health and Human Services
Office of Civil Rights
Hubert H, Humphrey Building
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201

You may also address your complaint to one of the regional Offices for Civil Rights. A list of these offices can be found online at http://www.hhs.gov/ocr/regmail.html.

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