Notice of Privacy Practices
This notice describes how Lonnie Paulos, MD may use and disclose your medical information, and how you may access this information. Please review it carefully.
If you have any questions about this Notice, please contact our Privacy Officer, Gabriela Pirraglio, at 1 (801) 733-9924, or by email at email@example.com.
We are required by law to maintain the privacy of your Protected Health Information, to notify you of our legal duties and privacy practices with respect to your health information, and to notify affected individuals following a breach of unsecured health information. This Notice summarizes our duties and your rights concerning your information. Our duties and your rights are set forth more fully in 45 CFR Part 164. We are required to abide by the terms of our Notice that is currently in effect.
This Notice of Privacy Practices describes Dr. Paulos’ practices, and that of any of our affiliates. All employees, staff, and other personnel will follow the terms of this notice. In addition, these entities, sites, and locations may share medical information with each other for treatment, payment, or health care operation purposes as described in this Notice.
Changes to this Notice:
We reserve the right to change the terms of our Notice at any time. Any revisions of the Notice will be effective for all Protected Health Information that we maintain at that time. To receive a copy of the revised Notice, you may contact our Privacy Officer and request that a revised copy be sent to you in the mail or it is also available online at . Additionally, you may also obtain a copy in the Admissions Office at the time of your next appointment.
Dr. Paulos’ Commitment to Protecting Medical Information:
We understand and appreciate the personal nature of any information related to you and your health. Dr. Paulos is committed to protecting your medical information, and are required by law to:
Ensure the privacy of your identifiable medical information;
Provide you with this notice of our legal duties and privacy practices with respect to your medical information; and
Follow the terms of the most current Notice.
This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information.
“Protected Health Information” refers to information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
You will be asked by Dr. Paulos to sign a consent form. Once you have consented to use and disclosure of your Protected Health Information for treatment, payment and health care operations by signing the consent form, Dr. Paulos will use or disclose your Protected Health Information as described in this Section.
Each category of uses and disclosures will be explained but not every use or disclosure in each category will be listed. However, every permissible use or disclosure will fall under one of the following categories.
Treatment: We will use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your Protected Health Information. We may disclose your Protected Health Information, as necessary, to doctors, nurses, counselors, physician assistants, nurse practitioners, or any other personnel involved in your care. For example, your Protected Health 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 Protected Health Information to another physician or health care provider who, at the request of your physician, becomes involved in your care by aiding with your health care diagnosis or treatment to your physician.
Payment: Your Protected Health Information will be used and disclosed, as needed, to obtain payment for your health care services. This may include uses and disclosures by and to the Health Information Management Department and our Business Office. Other uses and disclosures 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 deciding 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 Protected Health Information be disclosed to the health plan to obtain approval for the hospital admission.
Health care Operations: We may use or disclose, as needed, your Protected Health Information to support Dr. Paulos’ hospital operations and business activities. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, conducting or arranging for other business activities and compliance with state law.
For example, we may disclose your Protected Health Information to medical school students that see patients in our hospitals. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your Protected Health Information, as necessary, to contact you to remind you of your appointment. We will share your Protected Health Information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your Protected Health Information, we will obtain a written contract that contains terms that will protect the privacy of your Protected Health Information.
We may use or disclose your Protected Health Information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your Protected Health Information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures not described in this Notice will be made only with your written authorization, including most uses or disclosures of psychotherapy notes, for most marketing purposes or if we seek to sell your information. You may revoke your authorization by submitting a written notice to the Privacy Officer identified above. The revocation will not be effective to the extent Dr. Paulos has already taken action in reliance on the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made with Your Consent, Authorization or Opportunity to Object
We may use and disclose your Protected Health Information in the following instances. You will be granted the opportunity to agree or object to the use or disclosure of all or part of your Protected Health Information. If you are not present or able to agree or object to the use or disclosure of the Protected Health Information, then in our best professional judgment, Dr. Paulos may determine whether the disclosure is in your best interest. In this case, only the minimum necessary Protected Health Information relevant to your health care will be disclosed.
Others Involved in Your Healthcare: Unless you instruct us otherwise, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose Protected Health 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. Finally, we may use or disclose your Protected Health 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.
Emergencies: We may use or disclose your Protected Health Information in an emergency treatment situation. If this happens, Dr. Paulos’ staff shall attempt to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physician or any staff member is required by law to treat you and has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your Protected Health Information to treat you.
Communication Barriers: We may use and disclose your Protected Health Information if we attempt to obtain consent from you but are unable to do so due to substantial communication barriers and we determine, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your Protected Health Information in the following situations without your consent or authorization. These situations include, but are not limited to, the following:
Required By Law: We may use or disclose your Protected Health 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 minimum necessary. You will be notified, as required by law, of any such uses or disclosures. We may use or disclose your information to state agencies for registry purposes as appropriate and required under State of Utah law, for example, vital statistics, tumor, burn or trauma registries.
Public Health: We may disclose the minimum necessary amount of your Protected Health Information for public health activities to a public health authority that is permitted by law to collect or receive the information. These uses and disclosures may include, but are not limited to, the following:
To prevent or control disease, injury, or disability;
To report child abuse or neglect by making a telephone report to the appropriate authorities, and to follow this report with a written confirmation;
To report reaction to medication or problems with products as required by the Food and Drug Administration;
To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or
To notify the appropriate government authority if we believe a client has been the victim of domestic violence. We will only make this disclosure if you agree, and when consistent with the requirements or authorizations of applicable Utah and federal law.
Health Oversight: We may disclose Protected Health Information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure. 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.
Legal Proceedings: We may disclose Protected Health Information during any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose Protected Health Information, so long as applicable legal requirements are met, for law enforcement purposes. We may release the minimum necessary information if asked to do so by a law enforcement official:
In response to a proper court order or similar process;
In response to a subpoena for a staff member of Dr. Paulos;
About criminal conduct involving our facility;
Suspicion that death has occurred because of criminal conduct;
If a crime occurs on the premises of our facility; or
Medical emergency (not on Dr. Paulos’ premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose Protected Health Information to a coroner or medical examiner for identification purposes, cause of death determination, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose Protected Health 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. Protected Health Information may be used and disclosed for organ, eye, or tissue donation purposes.
Research: We may disclose your Protected Health Information to researchers when an institutional review board has reviewed the research proposal and established protocols to ensure the privacy of your Protected Health Information. In most cases, the medical information will be de-identified for privacy purposes.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your Protected Health 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 Protected Health Information if it is necessary for law enforcement authorities to identify or apprehend an individual. Any such disclosure would be limited to the minimum necessary, and would be made to someone involved in the prevention of the threat
Military Activity: When the appropriate conditions apply, we may use or disclose Protected Health 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 your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.
Workers’ Compensation: We may disclose your Protected Health Information for workers’ compensation and other similar legally established programs, in accordance with state and federal law regarding such disclosures.
National Security: We may disclose your Protected Health Information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Required Uses and Disclosures: By law, we must make minimum necessary disclosures when required to do so by state, federal, or local law.
2. Your Rights Regarding your Protected Health Information
Following is a statement of your rights with respect to your Protected Health Information and a brief description of how you may exercise these rights.
Right to Inspect and Copy: This means you may inspect and obtain a copy of Protected Health Information about you that is contained in a designated record set for as long as we maintain the Protected Health Information. A “designated record set” contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.
Under federal law, however, this generally does not apply to the following: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and Protected Health Information that is subject to law that prohibits access to Protected Health Information.
Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.
To inspect and/or copy your medical information maintained by Dr. Paulos, you must submit your request in writing to the Health Information Management Systems Department. You may be charged a fee for the administrative costs of retrieving, copying, mailing, and any other activities associated with your request.
Right to Request an Amendment: If you feel any of your medical information maintained by Dr. Paulos is incorrect or inaccurate, you may request an amendment of that information for as long as we maintain this information. In certain cases, we may deny your request for an amendment.
To request an amendment, your request must be made in writing and must include the reason for the request. All requests for amendment are to be submitted to the Health Information Management Department.
Dr. Paulos reserves the right to deny your request for amendment for any of the following reasons:
The information is complete and accurate;
We did not create the information;
The person or entity that created the information is no longer available to make the amendment;
The information is not part of the medical information kept by our facility; or
The request pertains to information that you are not permitted to inspect and copy.
You have the right to file a statement of disagreement with us. In turn, we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.
Right to an Accounting of Disclosures: This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices for a time frame of up to six years from the date of the request. It excludes routine disclosures, such as any we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes.
To request an accounting of disclosures, you must submit a written request to the Health Information Management Systems Department. Your request must state a time period, which may not exceed six years. You will not be charged for the first request for accounting within a twelve-month period; however, you may be charged a fee for the administrative costs of retrieving, copying, mailing, and any other activities associated with any additional requests for accounting. You will be notified of the costs involved and will have the option to withdraw your request at that time, before any costs are incurred.
Right to Request Restriction: You have a right to request that Dr. Paulos restrict the use or disclosure of any part of your Protected Health Information for the purposes of treatment, payment or health care operations. You may also request that your Protected Health Information be disclosed to family members or friends for notification purposes on an all or nothing basis. You must decide whether to grant disclosure to all family and friends, or to none.
You may request additional restrictions on the use or disclosure of information for treatment, payment or health care operations. We are not required to agree to the requested restriction except in the limited situation in which you or someone on your behalf pays in full for an item or service, and you request that information concerning such item or service not be disclosed to a health insurer.
Right to Request Confidential Communications: You have the right to request to receive confidential communications from Dr. Paulos by alternative means or at an alternative location. For example, you may wish to be contacted only at work or by mail. We will accommodate reasonable requests. 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.
This request must be made in writing to the Health Information Management Systems Department and must specify how and where you wish to be contacted.
Right to obtain a copy of this Notice: You have the right to obtain a copy of this Notice of Privacy Practices upon request. To receive a copy of this Notice, or any future revisions of the Notice, you may contact our Privacy Officer and request that a revised copy be sent to you in the mail or it is available online at . Additionally, you may also obtain a copy in the Admissions Office at the time of your next appointment.
If you believe your privacy rights have been violated, you may file a complaint with Dr. Paulosor with the Secretary of Health and Human Services. You may also call the Dr. Paulos’ Compliance/Privacy Hotline at 1-801-733-9924 to file a complaint with us, or contact our Privacy Officer for further information about the complaint process. We will not retaliate against you for filing a complaint.
If you have any questions about this Notice, please contact our Privacy Officer, Gabriela Piraglio, at 1 (801) 733-9924, or by email at firstname.lastname@example.org.
This Notice was published and becomes effective on September 29, 2017.