DISTRICT MEDICAL GROUP NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AN HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how the DMG Clinic may use and disclose your medical information to carry out treatment, payment or health care operation and for other purposes that are permitted or required by law.  This notice also describes your rights concerning your medical information.

  1. HOW WE WILL USE AND DISCLOSE YOUR MEDICAL INFORMATION

Your medical information may be used and disclosed by your provider, our office staff, and others outside of our office involved in your care and treatment for the purpose of providing health care services to you.  Your medical information may also be used and disclosed to pay your health care bills and to support the operation of your provider’s practice.

Following are examples of the types of uses and disclosures of your medical information that your provider’s office is permitted to make.  These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment: We may use or disclose our medical information to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with another provider.  We may also disclose medical information to other physicians or providers who may be treating you.  For example, your medical information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.  In addition, we may disclose your medical information from time to time to another physician or health care provider (e.g. a specialist or laboratory) who, at the request of your provider, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician or provider.

Payment:  We may use or disclose your medical information in order to obtain payment for your health care service provided by us or by another provider.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.  For example, obtaining approval for a hospital stay may require that your relevant medical information be disclosed to the health plan to obtain approval for the hospital admission.

Health Care Operations: We may use or disclose your medical information to improve the quality of care provided to clients or to support the business activities of the office.  Your medical information may be used to conduct quality improvement activities, to obtain audit, accounting or legal services, or to conduct business management and planning.  We will share your medical information with third party “Business Associates” that perform various activities (for example, billing or transcription services) for our office.  Whenever an arrangement between our office and a business associate involves the use or disclosure of your medical information, we will have a written contract that contains terms that will protect the privacy of your medical information.

Family Members, Friends and Others Involved in Your Care:  We may disclose your medical information to a family member or friend who is involved in your medical care or to someone who helps to pay for your care.  We may use or disclose your medical information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.  We may use or disclose your medical information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Required by the Law:  We may use or disclose your medical information to the extent that the use or disclosure is required by law.  The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.  You will be notified, if required by law, of any such uses or disclosures.

Public Health:  We may disclose your medical information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.  For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.

Communicable Diseases:  We may disclose your medical information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose medical information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections.  Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.

Abuse or Neglect: We may disclose your medical information to a public health authority that is authorized by law to receive reports of child abuse or neglect.  In addition, we may disclose your medical information if we believe that you have been a victim of abused neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration:  We may disclose your medical information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA regulated products or activities including to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance as required.

Legal Proceedings:  We may disclose medical information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose medical information, so long as applicable legal requirements are met, for law enforcement purposes, These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) a medical emergency (not on our practice’s premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose medical information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.  We may also disclose medical information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.  We may disclose such information in reasonable anticipation of death.  Medical information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your medical 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 medical information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your medical information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose medical information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security:  When the appropriate conditions apply, we may use or disclose medical information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of our eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.  We may also disclose your medical information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Worker’s Compensation: We may disclose your medical information as authorized to comply with worker’s compensation laws and other similar legally-established programs.

Inmates:  We may use or disclose your medical information if you are an inmate of a correctional facility and your physician created or received your medical information in the course of providing care to you.

  1. OTHER USES AND DISCLOSURES

We will ask for your written authorization if we plan to use or disclose your medical information for reasons not covered in this Notice.  You have the right to revoke the authorization at any time.  If you revoke your authorization we will no longer use or disclose your medical information for the reasons covered by your written authorization.  Please understand that we are unable to take back any disclosures already made with your authorization.

  1. YOUR RIGHTS
    1. Right to this Notice: You may request a paper copy of this Notice of Privacy Practices from us at any time.
    2. Right to request your medical information: You may request access to the medical information about you that we have in our records. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice use for making decisions about you.  As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.
  2. Right to request an amendment to your medical information: You may request an amendment of your medical information that you believe is incorrect or incomplete. In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
  3. Right to request a restriction of your medical information: You may request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations.  You may also request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your c are.   We are not required to agree to a restriction that you may request.  If we do agree to the requested restriction, we may not use or disclose your medical information in violation of the restriction unless it is needed to provide emergency treatment.

You may request that a health care item or service not be disclosed to your health plan for payment purposes or health care operations.  We are required to honor your request if the item or service is paid out of pocket and in full.  This restriction does not apply to the use or disclosure of your medical information related to your treatment.

  1. Right to request confidential communications from us by alternative means or at an alternative location. You may request that we communicate with you in a way that is more confidential. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.  We will not request an explanation from you as to the basis for the request.

In order to exercise any of your rights described above, contact the office manager for the necessary forms.

  1. CHANGES TO THIS NOTICE

We Reserve the right to amend the terms of this Notice.  If this Notice is amended, the amended terms will apply to all medical information that we maintain at that time.  You may request a copy of the revised version by calling the office and requesting that a copy be sent to you in the mail or asking for one at the time of your next appointment.

  1. QUESTIONS OR CONCERNS

If you have any questions about our privacy practices or any of the information contained in this Notice of Privacy Practices, or wish to register a complaint related to our privacy practices, please send your written complaint to the Privacy Officer at:

District Medical Group
Office of Corporate Compliance
2929 E. Thomas Rd.
Phoenix, AZ  85016

You may also file a written complaint with Secretary of the US Department of Health and Human Services (HHS) at:

Office for Civil Rights
US Department of Health and Human Services
90 7th Street, suite 4-100
San Francisco, CA 94103
Attn: OCR Regional Manager

You may also file a written complaint to the Arizona Department of Health at:

Arizona Department of Health
150 North 18th Avenue
Phoenix, AZ 85007
602-364-4764

We will not make you waive your right to file a complaint with HHS as a condition of receiving care from us, or penalize you for filing a complaint with HHS.

This notice was published and becomes effective on 01/01/2013.