contracting or spreading disease or condition; and 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 Activities: We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits: If you are involved in a lawsuit or dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement: We may release Health Information if asked by a law enforcement official if the information is:
(1) in response to a court order, subpoena, warrant, summons or similar process;
(2) limited information to identify or locate a suspect, fugitive, material witness, or missing person;
(3) about the victim of a crime even if, under limited circumstances, we are unable to obtain the person’s agreement;
(4) about a death we believe may be the result of criminal conduct;
(5) about criminal conduct on our premises; and
(6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors: We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.
National Security and Intelligence Activities: We may release Health Information to authorized federal officials for intelligence, counter- intelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose Health Information to authorized, federal officials so they may provide
protection for the President, other authorized persons, or foreign heads of state, or to conduct special investigations.
Inmates or Individuals in Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may
release Health Information to the correctional institution or law enforcement official.
This release would be if necessary:
(1) for the institution to provide you with health care;
(2) to protect your health and safety or the health and safety of others; or
(3) the safety and security of the correctional institution.
YOUR RIGHTS: You have the following rights regarding Health Information we have about you:
Right to Inspect and Copy: You have a right to inspect and copy Health Information that may be used to make decision about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request in writing, to our office.
Right to Amend: If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to our office.
Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment, or health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to our office.
Right to Request Restrictions: You also have the right to request a restriction or a limit on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to our office. We are not required to agree to all such requests. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communication, you must make your request, in writing, to our office. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice on our website, www.advancedfamilyicare.com. To obtain a paper copy of this notice please request it in writing.
Right to Electronic Record: You have the right to receive a copy of your electronic health records in electronic form.
Right to Breach Notification: You have the right to be notified if there is a Breach of privacy such that your Health Information is disclosed or used improperly or in an unsecured way.
CHANGES TO THIS NOTICE: We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of your current notice at our office. The notice will contain the effective date on the first page.
COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. All complaints must be made in writing. You will not be penalized for filing a complaint.
I acknowledge having been provided this notice.