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.
We understand that medical information about you and your health is personal. The physicians and staff of Monarch Medical Group (dba Monarch Medical Weight Loss Center) are committed to protecting medical information about you. This notice applies to the information and records we have about your health, health status, and the health care and service you receive at this office. Your health information may include information created and received by this office, may be in the form of written or electronic records or spoken words, and may include information about your health history, health status, symptoms,
examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity and similar types of health-related information.
This notice describes the information privacy practices followed by our employees, staff and other office personnel. We are required by law to maintain the privacy of your protected health information, provide you with this notice and abide by the terms of this notice. This notice will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose health information about you for purposes of treatment, payment, and/or healthcare operations without requesting or obtaining your consent or authorization. The following is a non-exhaustive list provided as an example of how the information may be used for treatment, payment, and/or healthcare operations.
- For Treatment. We may share health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, hospital staff, office staff and/or other personnel who are involved in taking care of you and your health.
For example, your doctor may be treating you for a heart condition and may need to know if you have other health
problems that could complicate your treatment. The doctor may use your medical history to decide what treatment is best for you. Your doctor may also share pertinent information about you as needed for on call coverage.
Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy, and scheduling lab work. Family members and other health care providers may be part of your medical care outside this office and may require information about you that we have. - For payment. We may use and disclose health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or another third party.
For example, we may need to give your health plan information about a service you received here so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will pay for the treatment. - For Health Care Operations. We may use health information for operations and activities such as quality control, quality assurance, and financial planning to help us provide efficient and quality care for you and our other patients. We may also disclose your health information to health plans that provide you insurance coverage and other health care providers that care for you. Our disclosures of your health information to plans and other providers may be for the purpose of helping these plans and providers provide or improve care, reduce cost, coordinate and manage health care and services, train staff and comply with the law.
- For Appointment Reminders. We may contact you as a reminder that you have an appointment for treatment or medical care at the office. Please notify us if you do not wish to be contacted for appointment reminders.
- For Identity Theft Prevention. We may collect copies of your government-issued photo identification or other documents at registration in order to verify your identity and help prevent identity theft.
- For Medication Management. We may access and share information about your medications with pharmacies and other medical providers through an online pharmaceutical database for the purpose of continued treatment.
SPECIAL SITUATIONS
We may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations:
To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Required By Law. We will disclose health information about you when required to do so by federal, state or local law.
Research. We may use and disclose health information about you for research projects that are subject to a special approval process. We will ask you for your permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the office.
Organ and Tissue Donation. If you are an organ donor, we may release health information to organizations that handle procurement or transplantation of organ, eye, or tissue. We may also release health information to an organ donation bank. Health information will be released as necessary to facilitate such donation and transplantation.
Military, Veterans, National Security and Intelligence. If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
Health Oversight Activities. We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.
Law Enforcement. We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
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. Information Not Personally Identifiable. We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Family and Friends. We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room during treatment or while treatment is discussed.
In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. For example, we may inform the person who accompanied you to the emergency room that you suffered a heart attack and provide updates on your progress and prognosis. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies, or medically related hand-outs/notes.
You may, from time to time, share with us photographs of yourself or your children, which are posted on public bulletin boards within our clinics. We will assume, unless you provide us with written instructions indicating otherwise, any photographs given to us are available for public display.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
The following uses and disclosures of your Protected Health Information will be made only with your written authorization:
- Uses and disclosures of Protected Health Information for marketing purposes; and
- Disclosures that constitute a sale of your Protected Health Information
Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization at any time by submitting a written revocation to the HIPAA Privacy Officer. If you revoke your authorization we will no longer use or disclose medical information about you for the reason covered by your written authorization, but disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.
In some instances, we may need specific, written authorization from you in order to disclose certain types of specially- protected information such as HIV, substance abuse, mental health, and genetic testing information.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy your health information in a designated record set, such as medical or billing records, that may be used to make decisions about your care. You may submit a written request to the Privacy Officer at:
Monarch Medical Group
Attn: Privacy Officer
363 High Street
Eugene, OR 97401
If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with this request.
We may deny your request to inspect and/or copy records in certain limited circumstances. If you are denied copies of or access to, health information that we keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Right to Amend. If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office. To request an amendment, complete and submit a MEDICAL RECORD AMENDMENT/CORRECTION FORM to Monarch Medical Group, Privacy Officer at the address listed above. We may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- We did not create, unless the person or entity that created the information is no longer available to make the Amendment.
- Is not part of the health information that we keep
- You would not be permitted to inspect and copy
- Is accurate and complete
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment, health care operations, and a limited number of special circumstances involving national security, correctional institutions and law enforcement. The list will also exclude any disclosures we have made based on your written authorization. To obtain this list, you must submit a written request to the Privacy Officer at the address listed above. It must state a time period, which may not be longer than six years and may not include dates before April 3, 2013. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment and/or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
Except as provided in the next two paragraphs, we are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or we are required by law to use or disclose the information.
Restrictions: We will comply with your request if you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
To request restrictions, you may complete and submit the REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMATION AND/OR CONFIEDENTIAL COMMUNICATION to the Privacy Officer at the address listed above.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
You must complete and submit the REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMATION AND/OR CONFIDENTIAL COMMUNICATION to the Privacy Officer at the address listed above. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to be notified of a Breach. You have the right to be notified in the event that we (or a Business Associate) discover a breach of unsecured protected health information that results in a significant risk of financial or reputational harm.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy.
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post the current notice in the office with its effective date in the upper right hand corner. You are entitled to a copy of the notice currently in effect.
COMPLAINTS
If you have any questions about this notice or our privacy practices, please contact our Privacy Officer at 541-687-4900. If you believe your privacy rights have been violated, you may file a complaint with Monarch Medical Group by contacting our Patient and Clinic Support department at:
Monarch Medical Group
Attn: Privacy Officer
363 High Street
Eugene, OR 97401
You may also contact the Secretary of the Federal Department of Human Services. All requests must be submitted in writing. We will not take any action against you for filing a complaint.
