HIPAA/Medical Information Privacy Notice
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED BY SMART PAIN MANAGEMENT, LLC AND HOW TO ACCESS THIS INFORMATION If you have any questions about this notice, please contact us.
OUR PLEDGE REGARDING YOUR HEALTH INFORMATION
We will create a record of the care and services you receive from us to provide you with quality care and to comply with legal or regulatory requirements.
We are committed to protecting your health information. This Notice applies to all of the records generated or received by us whether we documented the health information, or another doctor forwarded it to us. This Notice describes how we may use or disclose your health information, your rights to access your health information, and describe certain obligations we have regarding the use and disclosure of your health information.
The federal government has issued a regulation to provide safeguards for privacy and security of health information that may identify you. This rule was issued under a law called the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This document, called an ???Authorization,??? describes your rights and explains how your health information will be used and disclosed.
The privacy and security provisions of the Health Insurance Portability and Accountability Act (???HIPAA???) require us to:
Make sure that health information that identifies you is kept private;
Make available this notice of our legal duties and privacy practices with respect to health information about you; and follow the terms of the notice that is currently in effect.
Your Information. Your Rights. Our Responsibilities.
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.
You have the right to:
Get a copy of your paper or electronic medical record
Correct your paper or electronic medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we???ve shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have been violated
Our Uses and Disclosures
We may use and share your information as we:
Run our organization
Bill for your services
Help with public health and safety issues
Comply with the law
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
Address workers??? compensation, law enforcement, and other government requests
Respond to lawsuits and legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. You can ask us to correct health information about you that you think is incorrect or incomplete. We may say ???no??? to your request, but we???ll tell you why in writing within 60 days. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say ???no??? if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say ???yes??? unless a law requires us to share that information. You can ask for a list (accounting) of the times we???ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We???ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. You can complain if you feel we have violated your rights by contacting the Privacy Officer at firstname.lastname@example.org You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care Share information in a disaster relief situation If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission for: Marketing purposes Sale of your information
Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following way to: Treat you We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information? We are allowed or required to share your information in other ways ??? usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: