HIPAA Omnibus Notice of Privacy Practices
New England OB/GYN Associates, Inc.
200 Boylston Street, Suite 301 Chestnut Hill, MA 02467
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH 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 NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your protected health information to carry out treatment, payment or healthcare operations (TPO) 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” (“PHI”) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your PHI 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 example, your PHI 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.
Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, research, fundraising, and conducting or arranging for other business activities. For example, we may disclose your PHI to medical school students that see patients at our office. 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 PHI, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. If we use or disclose your PHI for fundraising activities, such as contacting you for our fundraising efforts, we will provide you the choice to opt out of those activities. You may also choose to opt back in.
USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION
We may use or disclose your PHI in the following situations without your authorization. These situations include: as required by law, public health issues, public safety issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, healthcare operations research, criminal activity, military activity and national security, workers’ compensation, and inmates. Under the law, we must also disclose your PHI to you upon your request. Under the law, we must also disclose your PHI when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.
USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object. Without your authorization, we are expressly prohibited from using or disclosing your PHI for marketing purposes. We may not sell your PHI without your authorization. We may not use or disclose most psychotherapy notes contained in your PHI. We will not use or disclose any of your PHI that contains genetic information that will be used for underwriting purposes. We will not use or disclose your PHI for future research projects, which do not pertain to healthcare operations research, without your authorization.
You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
The following are statements of your rights with respect to your PHI.
You have the right to inspect and copy your PHI (fees may apply) – Pursuant to your written request, you have the right to inspect or copy your PHI whether in paper or electronic format. You are also entitled to request a copy of your medical record, subject to certain reasonable restrictions and fees, where applicable. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, PHI restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality. If you wish to appeal any denial of access to your PHI, you may do so under the procedures set forth in 45 CFR 164.524 Access of individuals to protected health information. We will provide you with a summary of your health information pursuant to your written request, usually within 30 days of receipt of the written request.
You have the right to request a restriction of your PHI – This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed 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. Your physician is not required to agree to your requested restriction except if you request that the physician not disclose PHI to your health plan with respect to healthcare for which you have paid in full out of pocket. You may also revoke any prior authorization provided.
You have the right to request the manner in which you receive confidential communications – You have the right to request the manner in which confidential communication be provided to you by us, such as by having us call you at a home or office phone or send mail to a specific address. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e., electronically.
You have the right to request an amendment to your PHI – You have the right to request us to amend any health information about you that you think is incorrect or incomplete. If we deny your request for amendment, you have the right to file a statement of disagreement with us to be included in your PHI record, and we may prepare a rebuttal to your statement to be included in your PHI record and we will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures – Pursuant to your written request, you have the right to receive a list (accounting) of disclosures of your PHI, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred six years prior to the date of your request.
You have the right to receive notice of a breach – We will notify you if your unsecured PHI has been breached.
You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make copies of our new notice available at the front desk of our office if you wish to obtain a copy.
New England OB-GYN Associates, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
New England OB-GYN Associates, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-696-6775.
New England OB-GYN Associates, Inc. tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính.
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-696-6775
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. You can file a complaint directly with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave, SW, Washington, DC 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
Lisa Zajac, Practice Manager 617-467-6672 email@example.com
HIPAA COMPLIANCE OFFICER Phone email
We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.
New Patients – Please note that by signing our Consent Form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.