SUNSET ROAD MEDICAL ASSOCIATES
NOTICE OF PRIVACY PRACTICES
Effective: April 14, 2003
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.
Sunset Road Medical Associates uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of Sunset Road Medical Associates.
How Sunset Road Medical Associates May Use or Disclose Your Health Information
For Treatment. Sunset Road Medical Associates may use your health information to provide you with medical treatment or services. For example, information obtained by a health care provider, such as a physician, physician assistant, nurse, medical assistant, radiology technician, rehabilitation assistant, laboratory technician or other person providing health services to you, will record information in your record that is related to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions taken by them in the course of your treatment and note how you respond to the actions.
For Payment. Sunset Road Medical Associates may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third-party payor, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment.
For Health Care Operations. Sunset Road Medical Associates may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to:
o evaluate the performance of our staff;
o assess the quality of care and outcomes in your case and similar cases;
o learn how to improve our facilities and services; and
o determine how to continually improve the quality and effectiveness of the health care we provide.
Appointments. Sunset Road Medical Associates may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to the individual.
Required by Law. Sunset Road Medical Associates may use and disclose information about you as required by law. For example, Sunset Road Medical Associates may disclose information for the following purposes:
o for judicial and administrative proceedings pursuant to legal authority;
o to report information related to victims of abuse, neglect or domestic violence; and
o to assist law enforcement officials in their law enforcement duties.
Public Health. Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.
Decedents. Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.
Organ/Tissue Donation. Your health information may may be used or disclosed for cadaveric organ, eye or tissue donation purposes,
Research. Sunset Road Medical Associates may use your health information for research purposes when the research is being conducted under established protocols to ensure the privacy of your information.
Health and Safety. Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.
Government Functions. Specialized government fnctions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.
Workers Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Workers Compensation.
YOUR RIGHTS
As a patient at Sunset Road Medical Associates, you have certain rights regarding your Protected Health Information. We may ask that you submit a written request to exercise your patient rights. These rights include:
You have the right to request a restriction on certain uses and disclosures of your Protected Health Information. This means that you may ask us not to use or disclose any part of your Protected Health Information for purposes of treatment, payment, or health care operations. You may also request that any part of your Protected Health Information not be disclosed to family members or friends who may be involved in your care. Your request must state the specific restriction requested and state to whom you want the restriction to apply.
Sunset Road Medical Associates is not required to agree to such a restriction. If we do agree, we will abide by your restriction unless we need to use your Protected Health Information to provide emergency treatment. In addition, we may elect to terminate the restriction at any time.
You have the right to request to receive information from us by an alternative means or at an alternative location if you believe it would enhance your privacy. For example, you may request that we send written communications to an alternative address. We will attempt to accommodate all reasonable requests and will not request an explanation from you as to the basis for your request.
You have the right to inspect a copy of your Protected Health Information. If you would like to see or receive a copy of your Protected Health Information, we are required to provide you access to your Protected Health Information for inspection and copying within 30 days after receipt of your request. We will charge a fee to cover duplicating costs. In addition, there may be situations where we decide to deny your request for access. For example, we may deny your request if we believe the disclosure will endanger your life or health or that of another person. Depending on the circumstances of the denial, you may have a right to have this decision reviewed.
You have the right to amend your Protected Health Information. This means you may request an amendment of your Protected Health Information in our records for as long as we maintain this information. We will respond to your request within 60 days (with up to a 30-day extension. if needed). We may deny your request if, for example, we determine that your Protected Health Information is accurate and complete. If we deny your request, we will will send you a written explanation and allow you to submit a written statement of disagreement.
You have the right to receive an accounting of certain disclosures we have made of your Protected Health Information. An accounting is a record of the disclosures that have been made of Protected Health Information. This right generally applies to non-routine disclosures, i.e., for purposes other than treatment, payment, or health care operations, as described in this Notice, made in the six-year period prior to the your request (although you are free to request an accounting for a shorter period). We are required to provide the accounting within 60 days (with one 30-day extension, if needed) and to provide one accounting free of charge in any 12-month period. (For more frequent requests, a reasonable fee will be charged.)
You have the right to obtain a paper copy of this notice from Sunset Road Medical Associates. We reserve the right to change its information practices and to make the new provisions effective for all protected health information it maintains. Revised notices will be made available to you at the time of check-in as well as posted in the waiting room.
COMPLAINTS
If you believe your privacy rights have been violated, you have the right to report such alleged violations to Sunset Road Medical Associates, and we will promptly investigate the matter. You may file a complaint with Sunset Road Medical Associates by contacting our HIPAA Compliance Officer. Rest assured we will not retaliate against you in any way for filing a complaint about our privacy practices. You may also contact the Secretary of Health and Human Services.
You may contact our HIPAA Compliance Officer at (609) 387-8787 or by sending written correspondence to 911 Sunset Road, Burlington, NJ 08016.
This notice is effective on April 14, 2003.