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The offices of dr. Larry E. Forth
(referred to hereafter as the or this
"office") is committed to protecting
your personal medical information. The
creation of a record detailing the care
and services you receive helps this
office to provide you with quality
health care and complies with this
office's medical records retention
requirements. This notice applies to the
medical records maintained by this
office and it specifically details the
ways in which your medical information
may be used and disclosed to third
parties. This notice also details your
individual rights regarding your medical
records.
CHANGES
TO THIS PRIVACY NOTICE
We reserve the right to revise or amend
this privacy notice. Any revision or
amendment to this privacy Notice will be
effective for all of your records that
our practice has created or maintained
in the past, and for any of you records
that we may create or maintain in the
future. We will post a copy of our
current Notice in our offices is a
visible location at all times, and you
may request a copy of our most current
Notice at any time.
1. This office may use and/or disclose your medical
information consistent with a valid
consent granted by you for the purpose
of:
a. Treatment- In order to
provide you with the healthcare you
requires, this office will provide your
medical information to those healthcare
professionals, whether on this office's
staff or not, directly involved in your
care so that they may understand your
medical condition and needs. For
example, a physician treating you for
headaches may need to know about the
results of your latest examination by
our office.
b. Payment- In order to get
paid for services provided, this office
will provide your medical information
directly, or through a billing service,
to appropriate third party payers,
pursuant to their billing and payment
requirements. For example, this office
may need to tell your insurance
plan about a treatment you are
going to receive so that it can be
determined whether or not your plan will
cover the treatment.
c. Healthcare Operations-
In order to gain an overall view of
various elements of this office's
operations, individual medical
information may be collected, compiled
and disseminated. For example, this
office may utilize your medical
information in order to evaluate the
performance of our personnel in
providing care to you.
2. This office may use and/or disclose your medical
information without a consent, in the
following instances.
a. De-identified
Information- Information that is not
individually identifiable for that has
had all personally identifying
information removed, in accordance with
applicable laws, may be freely disclosed
by this office.
b. Business Associate- If
this office obtains satisfactory written
assurance from the business associate,
in accordance with the applicable laws,
that business associate will
appropriately safeguard the protected
information;
c. Personal
Representative- If under applicable
Georgia law a person has the authority
to represent you in making decisions
related to your health care, information
may be disclosed to that person without
your written consent;
d. Emergency Situations-
i. For the purpose of obtaining or
rendering emergency treatment to you, if
the office attempts to obtain consent
but is unable to do so;
ii. To a public or private entity
authorized by law or by its character to
assist in disaster relief efforts, or
the purpose of coordinating your care
with such entities in an emergency
situation;
e. Communication
Barriers- If, due to substantial
communication barriers or inability to
communicate, this office has been unable
to obtain consent and this office
determines, in the exercise of its
professional judgment, that your consent
to receive treatment is clearly inferred
from the circumstances;
f. Directory- In order to
maintain a directory of individuals in
this office, their location, their
condition in non-specific general terms,
and their religious affiliation. This
information can be made available in its
entirety to members of the clergy, and
except for religious affiliation, to
anyone asking for you by name.
g. Involvement in Care or
Payment- In accordance with applicable
laws, disclosure may be made to your
family member, other relatives, close
personal friends and/or any person
identified by you, of such information
that is relevant to the person's
involvement with your care or payment
related to your health care;
h. Notification- in order
to notify or assist in the notification
of a family member, a personal
representative or another person
responsible for your care of your
location or general condition;
i. Required by Law- When
and to the extent that such disclosure
is required by law, complies with and is
limited to the relevant requirements of
such law;
j. Criminal Conduct- To a
law enforcement official, that this
office believes in good faith
contributes evidence of criminal conduct
that occurred on the office premises;
k. Organ Procurement
Organizations- Or other entity engaged
in the procurement, banking or
transportation of organs for the purpose
of facilitating organ, eye or tissue
donation and transplantation;
l. Threat to Health
and/or Safety- If it is necessary to
prevent or lesson a serious and imminent
threat to the health and/or safety of a
person or the public, in accordance with
the applicable laws;
m. Appointment Reminders,
Treatment Alternatives and health
related Benefits- We may call or write
to remind you of scheduled appointments,
or that it is time to make a routine
appointment. We may also call or write
to notify you of other treatment s or
services available at our office that
might help you. Unless you tell us
otherwise we will mail you an
appointment reminder on a postcard
and/or leave you a message on your home
answering machine or with someone who
answers your phone if you are not home.
n. Military and Veterans-
If you are a member of the armed forces,
as required by military command
authorities;
o. Worker's Compensation-
In order to provide information or about
you to worker's compensation programs
designed to provide benefits for work
related injuries.
p. Pubic health Risks- In
order to prevent or control disease,
injury and disability and to report
child abuse or neglect;
q. Health Oversight
Activities- In order to provide
information to a health oversight
agency, such as the Georgia Department
of Community Health, for activities
authorized by law, including
inspections, investigations, audits and
licensure;
r. Lawsuits and Disputes-
In order to comply with a court or
administrative order in connection with
a lawsuit or dispute;
s. Coroner, Medical
Examiners and Funeral Directors- In
order to provide information to a
coroner, medical examiner or funeral
director for the purposes of
identification of an individual, the
determination of the cause of death and
for burial purposes; and
t. National Security and
Intelligence Activities- in order to
provide authorized governmental
officials with necessary intelligence
information for national security
activities and purposes authorized by
law.
3. Other uses and/or disclosures will be made only with
your written authorization and you may
revoke any authorization as set forth in
this notice.
4. Your
Individual Rights-
You have the right to:
a. Revoke any
authorization and/or consent, in
writing, at any time- To request a
revocation, please submit a written
request to the office's Privacy Officer,
as set for in Section 4(i) below;
b. request restrictions
on certain uses and/or disclosures as
provided by law; however this office is
not obligated to agree to any requested
restrictions- To request Restrictions,
please submit a written request to this
office's Privacy Officer, as set forth
in Section 4(i) below. In your written
request, you must inform this office
what information you want to limit,
whether you want to limit this office's
use or disclosure, or both, and to whom
you want the limits to apply. If this
office agrees to your request, we will
comply with the request unless the
information is needed in order to
provide you with emergency treatment;
c. Receive confidential
communications of protected health
information as required by law- To
request confidential communications, you
must make your request in writing to
this office's Privacy Officer, as set
forth in Section 4(i) below. We will
accommodate all reasonable requests.
Your request must specify how and where
you wish to be contacted.
d. inspect or copy
protected health information as provided
by law- this right includes access to
medical and billing records. To inspect
and copy health information, please
submit a written request to this
office's Privacy Officer, as set forth
in section 4(i) below. This office can
charge you a fee for the costs of
copying, mailing, or other supplies
associated with your request. This
office may deny you access to medical
information but you have the right to
have this denial reviewed as will be set
forth more fully in the written denial
reviewed as will be set forth more fully
in the written denial notice;
e. Amend incorrect or
incomplete protected information as
provide by law- To request an amendment,
please submit a written request to this
office's Privacy Officer, as set forth
in section 4(i) below. You must provide
a reason that supports your request for
the amendment. this office may deny your
request if it is not in writing, if you
do not provide a reason in support of
your request, if the information is not
part of the information you would be
permitted to inspect and copy, and/or
the information is accurate and
complete;
f. Receive and accounting
of disclosures (but not the uses) of
protected information as provided by
law- To request and accounting, please
submit a written request to this
office's Privacy Officer, as set forth
in section 4(i) below. The request must
state a time period that may not be
longer that six years and may not
include dates before April 14, 2003. The
request should indicate in what form you
want the list (such as a paper or
electronic copy). The first list you
request within a twelve month period
will be free but this office may charge
you for the costs of providing
additional lists. This office will
notify you of the costs involved and you
can decide to withdraw or modify your
request before any costs are incurred;
g. To receive a paper
copy of this notice from this office
upon request to this office's Privacy
Officer, as set forth in Section 4(i)
below;
h. To complain to this
office or to the secretary of HHS if you
beleive your privacy rights have been
violated. To file a complaint, please
contact this office's Privacy Officer,
as set forth in section 4(i) below;
i. To obtain more
information on, or have your questions
about your rights answered; you may
contact this office's Privacy Officer,
Virginia Wolfe at 800-426-1225.
5.
Office Rights & Requirements-
This office:
a. Is required by law to
maintain the privacy of protected health
information and to provide individuals
with notice of its legal duties and
privacy practices with respect to
protected information;
b. Is required to abide
by the terms of this notice;
c. reserves the right to
change the terms of this notice and to
make the new notice provisions effective
for all protected information that it
maintains.
d. Will:
i. Distribute any revised notice at a
Resident Council Meeting prior to
implementation; and
ii. Give to you, and you will be
requires to sign a recipt for, a revised
notice.
e. Will not retaliate
against you for filing a complaint.
6. This original notice is in effect as of April 14th,
2003.
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