PLEASE REVIEW IT CAREFULLY.
If you have any questions about this Notice, please contact the Privacy Officer for our organization at (319) 233-8911.
We are required by law to protect the privacy of your “protected health information” (PHI). This applies to all of the records involving your health care and the services which you receive at Clark and Associates, Inc. This Notice will explain how we may use and disclose your PHI and the obligations we have when doing so. It will also describe the rights you have about your PHI.
This Notice outlines Clark and Associates, Inc.’s privacy practices and will be followed by all of our employees, business associates necessary to our organization’s operations, and any other health care professionals authorized to access or add to your medical record. In addition, this Notice applies to all students and volunteers you may interact with while you’re at our office.
This Notice of Privacy Practices describes how we may use and disclose your PHI to carry out treatment, obtain payment for our services, perform health care operations for our organization, and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI.
Your PHI refers to all of your written and oral health information, including your demographic data that can be used to identify you. This is health information that is created or received by your health care providers, and that relates to your past, present or future physical or mental health or condition.
We are strongly committed to protecting your medical information. Each time you visit our office or receive our services at an outside location, a record of this visit is created. Generally, the record contains information about your diagnoses, symptoms, evaluation and/or test results, the service or device provided, treatment provided, and plan of care for your treatment. This record provides vital information pertaining to planning your treatment, providing treatment and any follow-up care which may be necessary, used as a means of communication with other health care professionals involved in your health care, as a legal document outlining the care you received at each visit, to provide an explanation to your insurance companies about the medical necessity of the services you received, as a means of educating other health care professionals, as a source of information for Public Health Officials (particularly in the case of an emergency), as a source for educating our personnel in order to evaluate results and strive to always improve the care provided to all of our patients, and to comply with other various legal requirements. Understanding your medical record and the PHI it contains helps you to work with your health care providers to ensure its accuracy, who and why others may be accessing it, and be able to make better informed decisions when you authorize access of your record to others.
We may electronically transmit some medical information about your care in order to obtain payment, and we use certain information in our day to day operations. This Notice will let you know about the various ways we use and disclose your medical information, further describe your rights, and our obligations with respect to the use or disclosure of your medical information. We will also ask that you acknowledge receipt of this Notice the first time you come to our office or receive any of our services. This written acknowledgment is needed because the law requires us to make a good faith effort to obtain your acknowledgment of our privacy practices.
We are required by law to comply with the following:
Make sure that any PHI that we have that identifies you is kept private by training personnel in all departments on privacy and confidentiality requirements;
Follow the terms of this Notice as long as they’re currently in effect. If we revise this Notice, we will follow the revised terms as long as they’re currently in effect;
Provide you with a copy of this Notice and make any revised Notices available to you;
Mitigate (to lessen the harm of) any breach of privacy or confidentiality
The categories listed below describe different ways that we may use and disclose your PHI. For each category of uses or disclosures listed, an explanation of what they mean and some common examples will be provided. Please be aware that not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information do fall within the categories below.
We are permitted to use and disclose your PHI to practitioners, technicians, residents or other personnel who are involved in taking care of you or providing you with services. For example, a practitioner treating you for a foot injury may need to know if you have diabetes because diabetes may slow the healing process. Different departments also may share your PHI in order to coordinate the different services that you need. We also may disclose your PHI to health care providers outside our organization who may be involved in your medical care, such as physicians who will provide follow-up care, physical therapy organizations, medical equipment suppliers, and skilled nursing facilities.
For Treatment: We are permitted to use and disclose your PHI to provide, coordinate, or manage your health care and any related treatment. This may be done by the personnel of Clark and Associates, Inc. who may need to share your PHI in order to coordinate the different services that you need from health care providers outside of our organization such as Physical Therapy, medical equipment, or Skilled Nursing organizations. This also includes the management of your health care with a third party that has already obtained your permission to have access to your PHI. For example, we would disclose your PHI, as necessary, to the physician that referred you to us in order to obtain clarification of your diabetes or to coordinate an appointment with a Physical Therapist. We will also disclose PHI to other health care providers who may be treating you when we have the necessary permission from you.
For Payment: We are permitted to use and disclose your PHI, as needed, to obtain payment for the services you receive from Clark and Associates, Inc. This 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; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, we may tell your health plan about an orthotic or prosthetic device you are going to receive in order to obtain prior approval from them or to determine whether your plan will cover the services.
For Healthcare Operations: We are permitted to use or disclose, as needed, your PHI in order to support the business operations of Clark and Associates, Inc. to make certain that all of our patients receive quality care. These activities include, but are not limited to, quality assessment for treatment and services, employee reviews to evaluate their performance in the care they provide to you, legal services, licensing, and conducting or arranging for other business activities.
To Business Associates For Treatment, Payment, or Healthcare Operations: We are permitted to use and disclose your PHI with third party “business associates” that perform various activities for Clark and Associates, Inc. Whenever an arrangement between our facility and a business associate involves the use or disclosure of your PHI, a written contract will exist containing terms that will protect the privacy of your PHI by all parties. For example, we may disclose your PHI to a company we contract with to bill your insurance company on our behalf or with a company who provides transcription services.
Treatment Alternatives: We may use or disclose your PHI, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Appointment Reminders: We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment.
Sign In Sheets: We will not use a sign-in sheet at the registration desk where you will be asked to sign your name. However, we may call you by your first name in the waiting room when our staff is ready to see you for your appointment.
Health Related Benefits and Services: We may use and disclose your PHI so that we may send you information about products or services that we believe may be beneficial to you. Clark and Associates, Inc. will never receive direct payment from a third party to send this communication to you. If you do not wish to receive such information, you may contact our Privacy Officer to request that these materials not be sent to you. We will never sell your information to a third party for marketing purposes.
Sale of the Practice: If we decide to sell this practice or merge or combine with another practice, we may share your PHI with the new owners.
Other Permitted or Required Uses and Disclosures of Your PHI That May Be Made Without Written Authorization
We are permitted to use and disclose your PHI in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the PHI, then Clark and Associates, Inc. personnel may, using their professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is relevant to your health care will be disclosed.
Others Involved in Your Healthcare: Unless you object, or in the event that you are not present, you are incapacitated, or in an emergency, Clark and Associates, Inc. may disclose to a member of your family, a relative, a close friend or any other person you identify, orally or in writing, your PHI as it directly relates to that person’s involvement in your health care, or payment for such 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 your PHI to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your general condition, status, and location. Finally, we may also use or disclose your PHI to an entity assisting in disaster relief efforts so that your family member, your personal representative or other person responsible for your care can be notified about your general condition, status and location.
Required By Law: We may use or disclose your PHI to the extent that the use or disclosure is required by federal, state or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health Activities: We may disclose your PHI for public health activities to public health authorities who are permitted by law to collect or receive the information. A disclosure under this exception would only be made to somebody in a position to help prevent the threat to public health. These activities include, but are not limited to, preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting vital events; public health and public health interventions, including notifying persons who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; or notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight: We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections; licensure and disciplinary actions; and civil, administrative and criminal proceedings or actions. 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.
Food and Drug Administration: We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose your PHI in response to a subpoena, discovery request or other lawful process by a party to a judicial or administrative proceeding, but only if efforts have been made to notify you about the request or to obtain an order from the court or administrative tribunal protecting the information requested.
Law Enforcement: We may disclose your PHI to a request from a law enforcement official in response to a court order, a court-ordered subpoena, warrant or summons, or similar process authorized by law. These law enforcement purposes might include (1) to identify or locate a suspect, fugitive, material witness or missing person, but only if limited information (e.g., name and address, date and place of birth, Social Security number, type of injury, date and time of treatment ) is disclosed; (2) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the victim’s agreement; (3) to report criminal conduct we believe occurred on our premises; (4) to report a death that we suspect may be the result of criminal conduct; and (5) in emergency circumstances to report a crime (not on the facility’s premises); the location of the crime or victims; or the identity, description or location of the person who likely committed the crime.
Coroners, Medical Examiners, and Funeral Directors: We may disclose your PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI 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. PHI may be used and disclosed for cadaveric organ, eye, or tissue donation purposes.
Research: Under certain circumstances, we may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI. This approval process must evaluate the project for its use of PHI and determine the research need with the need for our patients’ privacy. For example, the research may compare the recovery of patients who receive treatment for a specific condition with those who receive a different treatment plan for the same condition. This special approval process is not required when we allow researchers to access specific PHI for a project as long as the PHI they review does leave our premises.
Serious Threat to Health or Safety: Consistent with applicable federal and state laws, we may disclose your PHI, 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. Under certain circumstances, we may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: If you are a member of the armed forces, we may release PHI about you as required by military command authorities or for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits. We may also release PHI to the appropriate foreign military authority if you are a member of that foreign military service. We may also disclose your PHI to authorized federal officials for (1) conducting intelligence, counter-intelligence, and other national security activities authorized by law; or (2) in order to provide protection to the President of the United States, other authorized persons or foreign heads of state, or to conduct special investigations.
Workers’ Compensation: We may disclose your PHI as authorized to comply with workers’ compensation laws and other similar legally established programs that provide benefits for work-related illnesses and injuries.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official under specific circumstances such as (1) for the institution to provide health care to you; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
Uses and Disclosures of Protected Health Information (PHI) Based Upon Your Written Authorization
Following is a statement of your rights with respect to your PHI that Clark and Associates, Inc. maintains about you and a brief description of how you may exercise these rights.
Right To Inspect and Receive a Copy of Your PHI. You have the right to inspect and obtain a copy of your PHI contained in your medical and billing records and any other records that Clark and Associates, Inc. maintains and uses for making decisions about your care, for as long as we maintain the PHI.
To inspect and copy your medical information, you must submit a written request to Clark and Associates, Inc. A restriction request form may be obtained from the Clark and Associates, Inc. location where you received your services or by contacting our Privacy Officer at (319) 233-8911. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request.
We may deny your request in limited situations specified in the law. For example, you may not inspect or copy psychotherapy notes; or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and certain other specified protected health information defined by law. If you are denied access to PHI, you will be notified in writing. In some circumstances, you may have a right to have this decision reviewed by another health care professional chosen by us. The person conducting the review will not be the person who initially denied your request. We will comply with the decision in any review. Please contact our Privacy Officer at (319) 233-8911 if you have questions about access to your medical record.
Right to Request a Restriction of Your PHI. You have the right to 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 or disaster relief purposes as described in this Notice. Your written request must state the specific restriction requested and to whom you want the restriction to apply.
Clark and Associates, Inc. is not required to agree to a restriction that you may request. If we do agree, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide you with emergency treatment. Our Privacy Officer will notify you in writing whether we agree or do not agree with your request. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use and/or disclosure of the information; (3) to whom you want the limits to apply (for example, disclosures to your spouse); and (4) your contact address. A restriction request form is available from the Clark and Associates, Inc. location where you received your services or by contacting our Privacy Officer at (319) 233-8911.
Right to Request Confidential Communications. You have the right to ask that we communicate with you in a specific way or at a certain location. For example, you may ask that we only call you at your home telephone number or that we only contact you by mail at your home address. We will not ask you for a reason for your request. We will accommodate reasonable requests, whenever possible. Your written request must specify how and where you want us to contact you. A request form may be obtained from the Clark and Associates, Inc. location where you received your services or by contacting our Privacy Officer at (319) 233-8911.
Right to Amend Your PHI. You have the right to request an amendment of your PHI contained in your medical and billing records and any other records that Clark and Associates, Inc. uses for making decisions about you, for as long as we maintain the PHI. For example, you may feel that the PHI information in our records about you is incorrect or incomplete. You must make your request for amendment in writing and provide the reason or reasons that support your request. A request form may be obtained from the Clark and Associates, Inc. location where you received your services or by contacting our Privacy Officer at (319) 233-8911.
We may deny any request that is not in writing or does not state a reason supporting the request. We may deny your request for an amendment of any information that:
Was not created by us, unless the person that created the information is no longer available to amend the information;
Is not part of the PHI kept by or for us;
Is not part of the information you would be permitted to inspect or copy; or
Is accurate and complete.
We will notify you in writing of the decision regarding your request. If your request is approved, we will make the correction in our records and distribute the correction to other appropriate parties who will need to add it to their records and those you identify that you want to receive the corrected information. If we deny your request, we will notify you how you may file a complaint with us or the Department of Health and Human Services. You have the right to file a written statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer at (319) 233-8911 if you have questions about amending your medical record.
Right to an Accounting of Disclosures. This right only applies to disclosures for purposes other than treatment, payment or healthcare operations (except for those records that are maintained in an electronic format) as described in this Notice of Privacy Practices. It also excludes disclosures we may have made to you, to your relatives, friends or other persons who may be involved in your care, for notification or disaster relief efforts, for national security or intelligence purposes, or to correctional institutions or law enforcement officials. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations. You must submit a written request for disclosures in writing to the Clark and Associates, Inc. location where you received your services or by contacting our Privacy Officer at (319) 233-8911. You must specify a time period, which may not be longer than six years (except for electronic records which cannot be more than three years) and cannot include any date before April 14, 2003. You may request a shorter timeframe. Your request should indicate the form in which you want the list (i.e., on paper, etc.). You have the right to one free request within any 12 month period, but we may charge you for any additional requests in the same 12 month period. We will notify you about the charges you will be required to pay, and you are free to withdraw or modify your request in writing before any charges are incurred.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. Even if you have agreed to accept this notice electronically, you are still entitled to a paper copy if you desire. You may obtain a copy of this Notice from the Clark and Associates, Inc. location where you received your services or by contacting our Privacy Officer at (319) 233-8911. This Notice is also available at our website located at www.clarkprosthetics.com.
If you believe your privacy rights have been violated by Clark and Associates, Inc., you may complain directly to us or to the Department of Health and Human Services (HHS). You may file a complaint with us by contacting our Privacy Officer at (319) 233-8911. Or, you may contact the regional HHS office serving Iowa at the address or phone numbers listed below.
You may contact the Clark and Associates, Inc. Privacy Officer for further information about the complaint process or for additional information about any of the other matters identified in this Notice.
We will not retaliate against you in any way for filing a complaint.
Region VII – Kansas City (Iowa, Kansas, Missouri, Nebraska)
Office for Civil Rights
U.S. Department of Health and Human Services
601 East 12th Street – Room 248
Kansas City, MO 64106
Voice Phone (816)426-7277 / FAX (816)426-3686 / TDD (816)426-7065
We reserve the right to change the privacy practices that are described in this Notice of Privacy Practices. We also reserve the right to apply these changes retroactively to Protected Health Information (PHI) received before the change in privacy practices. You may obtain a revised Notice of Privacy Practices from the Clark and Associates, Inc. location where you received your services or by contacting our Privacy Officer at (319) 233-8911.
This notice was originally published and became effective on April 14, 2003. (History of Revision Dates: December 15, 2011)
*Please Note: Section 2 of this manual contains the version of this document provided to patients. The content of the distributed document is identical, but contains the company logo image and may vary in the font size of the text to facilitate easier reading and/or paper conservation when a printed version is requested.