During your treatment at Assure Neuromonitoring, doctors, nurses, and other caregivers may gather information about your medical history and your current health. This notice explains how that information may be used and shared with others. It also explains your privacy rights regarding this kind of information. The terms of this notice apply to health information created or received by Assure Neuromonitoring.
Assure Neuromonitoring is committed to protecting patient privacy. We are required by law to provide you with this Notice of Privacy Practices and to: make sure that medical information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to medical information about you; follow the terms of the notice that is currently in effect; and notify you in the event there is a breach of any unsecured protected health information about you.
With your authorization – For any purpose other than the ones described below, we may use or disclose your health information only when you have given us your written authorization.
Marketing – We will obtain your written authorization before using your health information to send marketing materials.
Highly confidential information – There are additional protections for certain confidential health information. For example: psychotherapy notes, diagnosis, prognosis or treatment for alcohol or drug dependency, HIV testing or results, may require a special authorization.
Selling your information – We will not sell your medical information without your written authorization.
Payment – We may use or disclose your information to obtain payment for services provided to you.
Treatment – We may disclose your information to another health care provider so they can treat you; to provide appointment reminders; or to provide information about treatment alternatives.
Health care operations – This includes using your information for certain activities that are necessary to operate the practice and ensure that patients receive quality care. For example, we may use your information to review the performance of staff.
Reminders – To remind you of appointments or other information about new or alternative treatments or other health care services for the purposes of care coordination.
As required by law – We will disclose your medical information if we are required to do so by federal, state or local law.
Business Associates – We may disclose information about you to our business associates so they can perform the services that we have contracted them to do for us. For example, we may disclose your information to attorneys, collection and accreditation organizations.
Public health activities – We may use and disclose your medical information when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person.
Research – We may use and disclose your medical information for research purposes either with your specific, written authorization or if the research has been approved and reviewed for privacy by our Institutional Review Board. Researchers may review your health information in a limited manner to determine if the study or participants are appropriate.
Special Circumstances – We may use and disclose your medical information in these special circumstances:
Organ and tissue donation
Health oversight activities (as required or allowed by law) Judicial and administrative proceedings
Workers compensation
Coroners, medical examiners and funeral directors National security and intelligence activities
Law enforcement
To others involved in your care – We may provide information to family, friends, or other people involved in your health care or payment for your health care (if permitted under state law).
To maintain our facility directory – We may include limited information about you in our directory while you are a patient. This could include your name, location in the facility and your religious affiliation if you provide this information to us. This directory information, except for your religious affiliation and condition, may be released to people who ask for you by name. This is so your family, friends, and clergy can know your location. Please notify Stephanie Krouse at (720)287-3093 if you do not want information disclosed.
Fundraising – you may be contacted to raise funds for Assure Neuromonitoring. You may opt out of these communications at any time by notifying the Privacy Officer identified below or following the instructions in the fundraising communication.
Right to inspect and copy your health information – You may request access to your health information to review or request copies of the information. This usually includes medical and billing records maintained by Assure Neuromonitoring.
Right to receive an electronic copy of your electronic medical record – You have the right to request an electronic copy of your medical information. If the form and format are not readily producible, we will work with you to create a reasonable electronic form or format. Please fill out and sign our Medical Records Request and submit it to our office to obtain a free copy of your medical record.
Right to request restrictions on the use or disclosure of your health information – You have the right to request restrictions on the use or disclosure of your medical record to your health plan for payment or health care operations if you have paid in full for the treatment out-of-pocket. This request must be in writing and identify what information you want to limit, how you want to limit the use and/or disclosure, and to whom you want the limits to apply. Please see our Medical Records Request for more information regarding specific restrictions.
Right to request to correct or amend your health information – You may ask us to correct your health information. We will consider all requests and may deny your request for legitimate reasons, for example, if we determine that the record is accurate and complete. To request a correction, you must contact our office in writing with your specific request and include appropriate documentation and reasoning behind your request.
Right to request confidential communications – You can request that we communicate with you about medical matters in a certain way.Please contact our office directly and inform us of your request for confidential communications.
Right to be notified of a breach – We will notify you in the event of a breach of your protected health information.
Right to receive an accounting of disclosures of your record – You can request a list of certain disclosures we have made of your health information. This information will not include disclosures for treatment, payment, health care operations, disclosures you have authorized and certain other disclosures. To request this list of disclosures you must submit your request in writing to our officeandmust state the time period for which you would like the accounting. If you request more than one accounting in any 12-month period, we may charge you a reasonable fee.
Right to a paper copy of this notice – You have the right to receive a paper copy of this notice and may ask for a copy at any time. This notice is also availableon our website: www.assureneuromonitoring.com.
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. If the terms of this notice are changed, Assure Neuromonitoring will provide you with a revised notice upon request and will post the revised notice in Assure Neuromonitoring’s designated locations and on our website:
www.assureneuromonitoring.com.
If you believe your privacy rights have been violated, you may file a complaint with us by notifying our Privacy Officer,Stephanie Krouse at (720)287-3093or the Secretary of Health and Human Services. We will not retaliate against you for filing a complaint.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. These rights are more fully described in Assure Neuromonitoring’s Notice of Privacy Practices. Assure Neuromonitoring is permitted to revise its Notice of Privacy Practices at any time. We will provide you with a copy of the revised Notice of Privacy Practices upon your request.
By signing below, you are acknowledging that you have received a copy of Assure Neuromonitoring’s Notice of Privacy Practices.
Patientname: __________________________
Patientrepresentative: _____________________________
If signed by patient representative, state authority to act on behalf of patient:
_________________________________
Signature:_________________________
Date: ____________________,20______
Post the Notice of Privacy Practices in a “clear and prominent” location where individuals will be able to read the notice.
Please note that this sample Notice addresses the Federal HIPAA regulations and does not incorporate state law(s) that could impose additional restrictions or authorization requirements when using or disclosing patient information. Always consider state and federal laws and regulations when releasing patient medical records.
Additional resources:
The regulations about Notice of Privacy can be found at 45 C.F.R. §164.520 www.ecfr/gov
Office for Civil Rights www.hhs.gov/ocr/privacy/
HHS/OCR Sample Business Associate Agreement www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.html