Notice Of Privacy Practices
Our Policy on Medical Record Privacy:
We are required by law to protect your personal medical
record by keeping it private and following certain rules
that dictate whether and when we can use or disclose your
information.
This notice informs you of the ways we may use and
disclose your health information. It also notifies you of
your rights and our obligations in our use and disclosure of
your health information.
We are required to give you this notice. You have the
right to request additional copies of this notice at any
time by contacting the privacy officer identified below.
This notice is effective April 14, 2003.
We reserve the right to change this notice. We reserve
the right to apply those changes to health information we
currently have, as well as information we may receive in the
future. If we change this notice, you may request a new copy
of the Notice at any time by contacting the privacy officer
identified below. We will also keep a current copy of the
notice on display in our office, and on our website,
www.indianaclinic.org. We are required to follow the terms
of the notice that is currently in effect.
How We May Use and Disclose Your Health Information:
We may use and disclose health information about you for
treatment, payment and healthcare operations.
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Treatment:
We may use your health information to provide you
with medical treatment. For example, we may use your
health information to provide you with services or
refer you to another physician. We may disclose your
health information to people outside of our medical
practice who may be involved in your medical care,
such as family members or clergy.
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Payment:
We may use and disclose your health information
to your health plan, insurance company, HMO or other
third-party in order to bill and collect for
services provided to you. For example, we may give
your health plan information regarding your
diagnosis and treatment in order to be paid for your
office visits, procedures, x-rays or laboratory
work.
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Healthcare Operations:
We may use and disclose your health information
in the process of running our medical practice. For
example, we may use or disclose your information if
we conduct quality assessment and improvement
activities to ensure that our patients receive top
quality medical care.
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Appointment Reminders:
We may use and disclose your health information
to contact you as a reminder that you have an
appointment with our practice.
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Appointment Reminders:
We may use and disclose your health information
to tell you about or recommend treatment
alternatives or health related benefits and services
that may be of interest to you.
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Fundraising/Marketing:
We may use and disclose your health information
to contact you to raise funds on behalf of our
medical practice or on behalf of a charitable
foundation that is related to us, or to update you
on the clinical or research activities at IU School
of Medicine.
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Individuals Involved in Your Care or Payment For
Your Care:
We may disclose your health information to a
family member or friend who is involved in your
medical care, or who helps pay for your care. We may
also tell your family or friends about your
condition; for example, if you are admitted to the
hospital. In addition, we may disclose your health
information in the event of a disaster relief
effort, so that your family can be notified about
your condition, status and location.
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Required By Law:
We will disclose your health information when we
are required to do so by federal, state or local
law.
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Public Health Risks:
We may disclose your health information for
public health activities, such as reporting disease,
injury or disability; births and deaths; child abuse
or neglect; defects, recalls or problems with drugs,
medical devices or other products; to prevent or
control disease, injury or disability; exposure to
or risk for diseases or conditions. We may also
notify authorities if we believe you have been the
victim of abuse, neglect or domestic violence, if we
are required or permitted by law to do so, or if you
agree to the notification.
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Health Oversight Activities:
We may disclose health information to a health
oversight agency authorized by law for audits,
investigations, inspections and licensure. Health
oversight agencies generally oversee the healthcare
system, government health programs (such as Medicare
and Medicaid), and the enforcement of civil rights
laws.
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Judicial and Administrative Proceedings:
We may disclose your health information in
response to a court order or administrative order.
We may also disclose your health information to
respond to a subpoena, discovery request or other
request that is not issued by a judge or
administrator, but only if efforts have been made to
inform you of the request or to get a protective
order for the information.
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Law Enforcement:
We may release health information if asked to do
so by a law enforcement official under the following
circumstances:
- If you have incurred certain injuries or
wounds that are legally required to be reported;
- In response to a court order, subpoena,
warrant, summons, investigative demand or
similar process;
- To identify or locate a suspect, fugitive,
material witness or missing person;
- About the victim of a crime if under certain
limited circumstances;
- About a suspicious death that we believe may
be the result of criminal conduct;
- About criminal conduct on our premises; AND
- In emergency circumstances to report a
crime, it’s location or information about the
person who may have committed the crime.
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Coroners, Medical Examiners and Funeral
Directors:
We may disclose your health information to a
coroner or medical examiner. This may be necessary,
for example, to identify or determine cause of
death. We may also disclose health information to
funeral directors as necessary to carry out their
duties.
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Organ and Tissue Donation:
We may use or disclose your health information to
organizations that handle organ procurement to
facilitate organ or tissue donation and
transplantation.
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To Avert A Serious Threat to Health or Safety:
We may use and disclose your health information
when necessary to prevent or lessen a serious threat
to the health and safety of you, the public or
another person. Any disclosure would be made to law
enforcement or someone else who can help prevent or
lessen the threat.
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Research:
We may use and disclose your health information
for medical research, without your authorization, if
an Institutional Review Board or similar body
approves the use and disclosure or if the use and
disclosure is solely for purposes preparatory to
research, such as preparing a research protocol or
if the use and disclosure is solely for research on
individuals who are deceased.
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Specialized Government Functions:
We may use or disclose your health information
for military command authorities, upon your
separation or discharge from military service, to
authorized officials. We may also disclose your
health information to the appropriate government
officials when it is necessary to conduct
intelligence or other national security activities
authorized by federal law. In addition, we may
release your health information if it relates to
protection of the President of the United States or
foreign heads of state. Finally, we may disclose
certain information related to members of the armed
services and foreign military services to the
appropriate personnel.
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Inmates:
If you are an inmate of a correctional facility
or under the custody of a law enforcement official,
we may disclose your health information to the
correctional institution or law enforcement official
in order to provide you with medical services,
protect you or others or to ensure the safety of the
correctional facility.
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Workers’ Compensation:
We may disclose your health information in
relation to workers’ compensation or similar program
established by law that provides benefits for
work-related illness or injuries. We may also
disclose your health information to your employer if
the healthcare services we provide to you are at the
request of your employer in order to carry out
work-place medical surveillance, but only if we
notify you first.
Your Rights Regarding Your Health Information:
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Your Right to Restrict Our Activities:
You have the right to request that we restrict
the use or disclosure of your health information for
treatment, payment or healthcare operations (as
described above). For example, you may request that
we limit what information we provide to your family
members regarding medication you may be taking.
We are not required to agree to your request. If
we agree to your restrictions or limitations, we
will comply with your wishes unless the information
is needed to provide emergency treatment to you. To
request restrictions or limitations, you must make a
written request to the Privacy Officer. In your
written request you must tell us (1) what
information you want to limit; (2) whether you want
to limit use of the information and/or disclosure of
the information; and (3) to whom the limitations or
restrictions will apply (for example, disclosure to
your spouse). If we agree to your restrictions or
limitations, the Privacy Officer will notify you in
writing.
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Your Right to Request Confidential
Communications:
You have the right to tell us how you would like
us to communicate with you. For example, you may ask
that we call you at a certain phone number, or you
may tell us whether we may leave a message for you.
To request confidential communications, you must
make your request in writing to the Privacy Officer
listed below. Your request must specify how or where
you wish to be contacted. We will follow all
reasonable requests for confidential communications.
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Your Right to Inspect and Copy:
You have the right to inspect and copy your
health information, including most of your medical
records. You do not have the right to review any
psychotherapy notes, information created for use in
legal actions or other information covered by
certain laws.
If you would like to inspect and/or copy your
health information, you must submit your request in
writing to the privacy officer listed below. If you
request a copy of the information, we may charge you
a reasonable fee for copying, postage or other
expenses related to your request.
We may deny your request to inspect and/or copy
your health information. If we do, you may request
that the denial be reviewed. We will choose a
licensed healthcare professional to review your
request and the denial. The person conducting the
review will not be the person who denied your
request. We will comply with the outcome of the
review.
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Your Right to Amend:
If you feel that your health information is
incorrect or incomplete, you may ask us to amend
your records. To request an amendment, you must
submit a written request to the privacy officer.
Your request must state the reason you believe an
amendment is necessary.
We may deny your request for an amendment if it
is not in writing or does not include a reason to
support the request. In addition, we may deny your
request if: (a) we did not create the information
(unless the entity that created the information is
no longer available); (b) the information is not in
our possession or control; (c) you would not be
permitted to inspect or copy the information; or (d)
the information is accurate and complete.
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Your Right to an Accounting of Disclosures:
You have the right to request an "accounting of
disclosures". This is a list of certain disclosures
of your health information that we have made.
To request this list of disclosures, you must
submit a written request to the privacy officer.
Your request must state a time period for which the
accounting is requested. The time period may not be
longer than six years and may not include dates
before April 14, 2003. You may receive one list per
year without charge. We may charge you for the costs
of providing additional lists within one year after
your first request. We will notify you of the cost
involved and you may choose to withdraw or modify
your request if you do not wish to pay the cost.
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Your Right to Receive a Paper copy of This
Notice:
If you are receiving this notice electronically,
you have the right to request a paper copy of this
notice by making a request to the privacy officer.
Changes to This Notice:
We reserve the right to change this notice, and to apply
the revisions or changes to health information we already
have about you, in addition to information we create or
receive in the future.
Complaints:
If you believe your privacy rights have been violated,
you may file a complaint with the Privacy Officer. You may
also file a complaint with the United States Secretary of
the Department of Health and Human Services. We encourage
your feedback regarding our privacy policies, and we will
not retaliate against you in any way if you file a
complaint.
Other Uses of Your Health Information:
This notice only describes the ways we may use and
disclose your health information without obtaining further
permission from you. There may be other reasons we request
to use or disclose your health information. If we need to do
so, we are required to get your written authorization. If
you grant us this further authorization, you may revoke it
at any time by giving us written notice that you no longer
authorize us to use or disclose your health information for
those purposes. Other uses and disclosures of health
information not covered by this notice or the laws that
apply to us will be made only with your written permission.
If you provide us permission to use or disclose your health
information, you may revoke that permission, in writing, at
any time. If you revoke your permission, we will no longer
use or disclose your health information for the reasons
covered by your written authorization. We are, however,
required to retain our records of the care that we provided
to you, and we are unable to take back any disclosures we
have already made with your permission.
Contact Information:
For questions regarding this notice, or to receive
further information, please contact the HIPAA Privacy
Officer at:
INDIANA CLINIC
INTERIM PRIVACY OFFICER
Carol Karp
340 W. 10th St.,
FS 5100
Indianapolis,
IN 46202-3082
work(317) 278-3500
Toll Free:
work1-888-944-36271-888-944-DOCS
(3627)
Fax:
(317) 278-3502
Indiana Clinic Confidential Compliance
Notification Line: 1-888-878-7836