PRIVACY PRACTICES

Download RTF Version / Download PDF Version

HIPAA Form C
Notice and Acknowledgment
Connecticut Vascular Center, P.C.

Brief Overview of HIPAA Requirements:
The goal of the HIPAA privacy rule is to protect patients' right to confidentiality in matters involving their healthcare. In general, the privacy rule does the following:

Provides restrictions on uses and disclosures of patient health information. The privacy rule sets forth the instances in which protected patient information can be used within Connecticut Vascular Center, P.C. or disclosed by us to outside parties;

Creates individual patient rights to inspect and copy their records, to amend erroneous information, to request certain restrictions on the use and disclosure of patient information, to file written complaints, and to receive notice of a provider's privacy policy.

Connecticut Vascular Center, P.C. has implemented privacy policies and procedures, and conducted privacy education with all employees to comply with the HIPAA regulations to protect patients' right to confidentiality.

Acknowledgment:

I acknowledge that I have received the attached Notice of Privacy Practices.

If Personal Representative's signature appears above, please describe Personal Representative's relationship to the patient:

NOTICE OF PRIVACY PRACTICES
FOR
CONNECTICUT VASCULAR CENTER, P.C.

(Referred to in this document as "the provider," "CVC")

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.
This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). This Notice 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 in some cases. Your "protected health information" means any of your written and oral health information, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.

OUR PLEDGE TO YOU
We understand that medical information about you is personal and we are committed to protecting that information. Your medical record is created as part of providing you with quality care, as well as for the purpose of meeting legal requirements. This notice applies to all the records of your care generated or maintained by CVC. We are required by law to: Keep medial information about you private; Give you this notice of our legal duties and privacy practice with respect to medical information about you; and Follow the terms of the privacy practice notice that is currently in effect.

I. HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
We may use and disclose medial information about you without your prior authorization for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Other examples of such uses and disclosures include: contacting you for appointment reminders, or to inform you about possible treatment options and heath-related benefits or services that may be of interest to you. Disclosures of your protected health information for the purposes described in this Notice may be made in writing, orally, or by facsimile.

A. 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 for treatment purposes. For example, we may disclose your protected health information to a pharmacy to fulfill a prescription, to a laboratory to order a blood test, or to a home health agency that is providing care in your home. We may also disclose protected health information to other physicians who may be treating you or consulting with your physician with respect to your care. In some cases, we may also disclose your protected health information to an outside treatment provider for purposes of the treatment activities of the other provider.

B. Payment. Your protected health information will be used, as needed, to obtain payment for the services that we provide. This may include certain communications to your health insurer to get approval for the treatment that we recommend. For example, if a hospital admission is recommended, we may need to disclose information to your health insurer to get prior approval for the hospitalization. We may also disclose protected health information to your insurance company or to Medicare to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. In order to get payment for your services, we may also need to disclose your protected health information to your insurance company to demonstrate the medical necessity of the services or, as required by your insurance company, for utilization review. We may also disclose patient information to another provider involved in your care for the other provider's payment activities.

C. Operations. We may use or disclose your protected health information, as necessary, to support our health care operations (such as comparing patient data to improve treatment methods). In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.

We may use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may communicate medical information about you, without your prior authorization, for the following: public health purposes; abuse or neglect reporting; health oversight audits or inspection; to fulfill a request from a medical examiner; funeral arrangements and organ donations; worker's compensation claims; emergencies; national security needs and other specialized government functions; and for members of the Armed Forces as required by Military Command authorities. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders.

The Inpatient Care Facility (ICF) has procedures, which protect patient privacy while allowing information to be given to those whom the patient designates. Patients are informed of these procedures upon their admission to the ICF.

II. Uses and Disclosures Permitted Without Authorization But With Opportunity to Object
We may disclose your protected health information to your family member or a close personal friend if it is directly relevant to the person's involvement in your care or payment related to your care. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.

You may object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to the person's involvement with your care, we may disclose your protected health information as described.

III. Uses and Disclosures, Which You Authorize
Other than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.

IV. Your Rights
You have the following rights regarding your health information:

A. Your rights regarding your medical record. In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care. To do so, you must submit a written request to the address below. We may charge a fee for the cost of copying, mailing, or related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision to our Privacy Officer whose contact information is listed at the end of this notice.

B. The right to request a restriction on uses and disclosures of your protected health information. You may ask us not to use or disclose certain parts of your protected health information for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

The provider is not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If the provider does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Privacy Officer.

C. The right to request that we amend the records. If you believe that information in your record is incorrect or incomplete, you have the right to request that we correct the records. Please send a written request to the address below, providing your reason for requesting the amendment. We may deny your request if the information was not created by us; if it is not part of the medical information maintained by us; or if we determine that your record is accurate; or under certain other circumstances. You may submit a written statement of disagreement with a decision by us not to amend a record to our Privacy Officer.

D. The right to receive an accounting. You have the right to request a list of disclosures we have made of our health information. The list will not include: 1) disclosures made for treatment, payment, and health care operations, as previously described; or 2) disclosures made in circumstances where you have given specific and separate authorization or 3) certain other disclosures in accordance with the law.

Please note that this policy will be in effect beginning April 14, 2003. You must indicate the period for which you request the list of disclosures, which can be up to six years before the date of your request. Disclosure lists will be kept for a rolling period of six years. Requests can be made for any time within the six-year period and must be submitted in writing to our Privacy Officer.

E. The right to receive confidential communications. You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home. You may notify us of how you would like us to communicate with you by writing to our Privacy Officer.

F. The right to receive a paper copy of this notice. You may receive a paper copy of this notice upon request even if you have previously agreed to receive this notice electronically.

G. If we change our policies. If we change our policies, the changes will apply to medical information we already hold, as well as new information generated after the change occurs. Before we make a significant change in our policies, we will post the notice of the new policies in prominent areas and on our web site at, www.ctvascularcenter.com. You can receive a copy of the current policy at any time if you have previously agreed to receive this notice electronically. Copies of the current notice will be available at all times at the office. The effective date is printed at the end of the notice.

H. To register a complaint. If you are concerned that your privacy rights may have been violated, or you disagreed with a decision we made about access to your records, you may contact our Privacy Officer by writing to: Connecticut Vascular Center, P.C., 2200 Whitney Avenue, Suite 210, Hamden, CT 06518, ATTN: Privacy Officer.

You may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Privacy Officer can provide you the address. You will not experience penalties or retaliation for filing a complaint.

This notice is effective as of April 14, 2003


Rev. 3/03