For Protected Health Information
Effective Date: March 17, 2012
Valley Medical Weight Control, P.C.
Notice of Privacy Practices
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!
The clinic is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Examples of Uses of Your Health Information for Treatment Purposes are:
- Plan your care and treatment;
- Provide treatment by our physician or a member of our staff;
- Obtain treatment information about you and record it in a health record
- Communicate with other providers such as referring physician
- Make you aware of services and treatments that may be of interest to you
- Comply with state and federal laws that require us to disclose your health information.
- During the course of your treatment, the physician determines if he/she will need to consult with another specialist in the area. He/she will share the information with such specialist and obtain his/her input.
- Should you pursue a chargeback through your credit card company, or otherwise accrue an unpaid balance, you forfeit your right to privacy and the information required to pursue collection and/or legal action will be disclosed in seeking remuneration.
Example of Use of Your Information for Health Care Operations:
We may obtain services from other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.
Your Health Information Rights
The health and billing records we maintain are the physical property of the office/clinic. The information in it, however, belongs to you. You have a right to:
- Request a restriction on certain uses and disclosures of your health information by delivering the request to our clinic — we are not required to grant the request, but we will comply with any request granted;
- Request a restriction on disclosures of medical information to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment; and the PHI pertains solely to a health care service for which the provider has been paid out of pocket in full)—we must comply with this request;
- Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information (“Notice”) by making a request at our clinic;
- Request that you be allowed to inspect and copy your health record and billing record – you may exercise this right by delivering the request to our clinic;
- Appeal a denial of access to your protected health information, except in certain circumstances;
- Request that your healthcare record be amended to correct incomplete or incorrect information by delivering a request to our clinic. We may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the health information kept by or for the clinic;
- Is not part of the information that you would be permitted to inspect and copy; or,
- Is accurate and complete.
If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records.
- Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office/clinic;
- Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a request to our clinic. An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person’s involvement in your care or in payment for such care; or uses or disclosures to notify family or others responsible for your care of your location, condition, or your death.
- Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to our clinic, except to the extent information or action has already been taken.
If you want to exercise any of the above rights, please contact Jodi Jaffe at 3801 N. 24th Street, Phoenix, AZ 85016, in person or in writing, during regular, business hours. She will inform you of the steps that need to be taken to exercise your rights.
The clinic is required to:
- Maintain the privacy of your health information as required by law;
- Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
- Abide by the terms of this Notice;
- Notify you if we cannot accommodate a requested restriction or request; and,
- Accommodate your reasonable requests regarding methods to communicate health information with you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Jodi Jaffe at 480-968-5673.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Jodi Jaffe. You may also file a complaint by mailing it or e-mailing it to the clinic at 3141 S. McClintock Dr #4 Tempe, AZ 85282 or email@example.com.
- We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the clinic.
- We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.
Other Disclosures and Uses
Communication with Family
- Using our best judgment, we 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 in payment for such care if you do not object or in an emergency.
- Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
- We may disclose 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 protected health information.
- We may use and disclose your protected health information to assist in disaster relief efforts.
Food and Drug Administration (FDA)
- We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
- If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
- As authorized by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.
Abuse & Neglect
- We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
- We may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.
- We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.
- Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
- We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.
- To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
For Specialized Governmental Functions
- We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
Coroners, Medical Examiners, and Funeral Directors
- We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients of Covered Entities to funeral directors as necessary for them to carry out their duties.
- Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under “Your Health Information Rights.”
- If we maintain a website that provides information about our entity, this Notice will be on the website.