EXPLANATION OF DISCLOSURE OF PROTECTED HEALTH  INFORMATION DATA
In Compliance with HIPAA
(Health Insurance Portability and Accountability Act of 1996)

This notice is to inform you that it is our office policy to use your health information data only as deemed necessary to give you quality medical care.  Our staff has been instructed not to release or discuss patient information away from the office.  Information is only to be released to other sources (i.e. insurance companies, physicians, pharmacies,  opticians, contact lens providers) as needed to render care and payment.  When you filled out our patient information  form at your first visit, you signed an authorization that authorized us to release information to your insurance company (ies). You may be asked to sign a records release, if we need to send records to another physician.

We do not sell or give our patient’s PHI (protected health information) to vendors or marketing firms. PHI is individually  identifiable health information that is transmitted or maintained in any  form. We send PHI  electronically to Medicare via modem.  It is protected by a firewall.

1. Medicare forwards PHI to numerous secondary carriers.
2. We send paper insurance claims by mail.
3. We are required to disclose PHI to individuals seeking to access their own PHI and to Department of  Health and Human Services for compliance and enforcement  purposes.
4. There are instances  that we may use or disclose PHI information without the consent or authorization of the patient:  If requested by law enforcement  agencies, disclosure to Coroners or Medical Examiners, Organ procurement  organizations, Specialized government functions(military) and Worker’s  Compensation.  For Public Health  activities, Elder or Child Abuse, Health Oversight activities(state licenser, etc.), Judicial and Administrative Proceedings and Emergency situations with  serious threats to health and safety.
5. We may release PHI  after acknowledgment of our privacy practices for treatment, payment and health  operations if there is inferred or verbal permission.
6. A patient may request restrictions to the release of their PHI; however we are required to fulfill the HIPPA requirements.
7. It is our practice to send recall notices to our patients.  We do this with the minimum amount of information on the card.  If you do not wish this to be done, please inform.
8. If necessary we will leave messages on patient’s answering machines.  If you do not wish this to be done, please inform us.
9. A patient may request to see their medical record, and request that that record be amended.
10. A patient may request an accounting of any disclosures of their record.
11. A patient may request a paper copy of this notice.
12. We will ask that you to acknowledge receipt of this document by having you sign an acknowledgment and retain it in your record. 

We are required by law to safeguard your Protected  Health Information and we are bound by the terms of this notice, and subsequent revisions of this notice. If a patient has a concern with our privacy practice, contact us by giving a written notice to our office manager, Joanne Roper. 

If a patient has a concern about our privacy practice and wishes to contact the Department of Health and Human Services they can be reached at 1-800-738-8816. 

Copyright © 2011,  Sally Mellgren, MD. All Rights Reserved.