CONSENT TO RELEASE MEDICAL INFORMATION

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

Overview

The law requires us to keep your protected health information (PHI) private in accordance with this Notice of Privacy Practices (Notice), as long as this Notice remains in effect. We are also required to provide you with a paper copy of this Notice, which contains our privacy practices, our legal duties, and your rights concerning your PHI.

From time to time, we may revise our privacy practices and the terms of our Notice at any time, as permitted or required by applicable law. Such revisions to our privacy practices and our Notice may be retroactive. Our Notice will be updated and made available to our patients upon request prior to any significant revisions of our privacy practices and policies. In the event our privacy practices are revised, a notice of that change will be prominently displayed in patient areas of the office so that patients may request a copy of the revised policies.  

Our Privacy Practices

Use and Disclosure: We may use or disclose your PHI for treatment, payment or health care operations via paper copy or electronic form. For your convenience, we have provided the following examples of such potential uses or disclosures:

Treatment. Your PHI may be used by or disclosed to any physicians or other health care providers involved with the medical services provided to you. This includes disclosure of your PHI to other healthcare providers through electronic exchanges such as patient registries and Health Information Exchanges (HIEs).

Payment. Your PHI may be used or disclosed in order to collect payment for the medical services provided to you.

Health Care Operations. Your PHI may be used or disclosed as part of our internal health care operations. Such health care operations may include, among other things, quality of care audits of our staff and affiliates, conducting training programs, accreditation, certification, licensing, or credentialing activities.

Authorizations: We will not use or disclose your medical information for any reason except those described in this Notice, unless you provide us with a written authorization to do so. We may request such an authorization to use or disclose your PHI for any purpose, but you are not required to give us such authorization as a condition of your treatment. Any written authorization from you may be revoked by you in writing at any time, but such revocation will not affect any prior authorized uses or disclosures.

Patient Access: We will provide you with access to your PHI, as described below in the Individual Rights section of this Notice. With your permission, or in some emergencies, we may disclose your PHI to your family members, friends, or other people to aid in your treatment or the collection of payment. A disclosure of your PHI may also be made if we determine it is reasonably necessary or in your best interests for such purposes as allowing a person acting on your behalf to receive filled prescriptions, medical supplies, X rays, etc

Locating Responsible Parties: Your PHI may be disclosed in order to locate, identify or notify a family member, your personal representative or other person responsible for your care. If we determine in our reasonable professional judgment that you are capable of doing so, you will be given the opportunity to consent to or to prohibit or restrict the extent or recipients of such disclosure. If we determine that you are unable to provide such consent, we will limit the PHI disclosed to the minimum necessary.

Disasters: We may use or disclose your PHI to any public or private entity authorized by law or by its charter to assist in disaster relief efforts.

Required by Law: We may use or disclose your medical information when we are required to do so by law. For example, your PHI may be released when required by privacy laws, workers' compensation or similar laws, public health laws, court or administrative orders, subpoenas, certain discovery requests, or other laws, regulations or legal processes. Under certain circumstances, we may make limited disclosures of PHI directly to law enforcement officials or correctional institutions regarding an inmate, lawful detainee, suspect, fugitive, material witness, missing person, or a victim or suspected victim of abuse, neglect, domestic violence or other crimes. We may disclose your PHI to the extent reasonably necessary to avert a serious threat to your health or safety or the health or safety of others. We may disclose your PHI when necessary to assist law enforcement officials to capture a third party who has admitted to a crime against you or who has escaped from lawful custody.

Deceased Persons: After your death, we may disclose your PHI to a coroner, medical examiner, funeral director, or organ procurement organization in limited circumstances. 

Research: Your PHI may also be used or disclosed for research purposes only in those limited circumstances not requiring your written authorization, such as those which have been approved by an institutional review board that has established procedures for ensuring the privacy of your PHI.

Military and National Security: We may disclose to military authorities the medical information of Armed Forces personnel under certain circumstances. When required by law, we may disclose your PHI for intelligence, counterintelligence, and other national security activities.

Fundraising: The Practice does not participate in any type of fund-raising, nor will we sell or give your name to any organization or individual for that purpose. 

Solicitation: The Practice does not release any information about you for solicitation purposes. We may however, call you about a missed appointment, or to change an appointment. We may also send you written notice of an upcoming appointment or appointment change. Upon your request, we may also mail you a reminder that your yearly physical is due. Only as instructed by your provider, we may also advise you of a new medication or course of treatment that is appropriate for you.

Your Individual Rights

Access and Copies: In most cases, you have the right to review or to purchase copies of your PHI by requesting access or copies in writing to our Privacy Officer. Please contact our Privacy Officer regarding our copying fees.

Disclosure Accounting: You have the right to receive an accounting of the instances, if any, in which your PHI was disclosed for purposes other than those described in the following sections above: Use and Disclosures, Patient Access, and Locating Responsible Parties. For each 12-month period, you have the right to receive one free copy of an accounting of certain details surrounding such disclosures that occurred after April 13, 2003. If you request a disclosure accounting more than once in a 12-month period, we will charge you a reasonable, cost-based fee for each additional request. Please contact our Privacy Officer regarding these fees.

Additional Restrictions: You have the right to request a restriction on our use or disclosure of your PHI for treatment, payment or health care operations.

Alternate Communications: You have the right to request that we communicate with you about your PHI by alternative means or in alternative locations. We will accommodate any reasonable request if it specifies in writing the alternative means or location, and provides a satisfactory explanation of how future payments will be handled.

Amendments to PHI: You have the right to request that we amend your PHI. Any such request must be in writing and contain a detailed explanation for the requested amendment. Under certain circumstances, we may deny your request but will provide you a written explanation of the denial. You have the right to send us a statement of disagreement to which we may prepare a rebuttal, a copy of which will be provided to you at no cost. Please contact our Privacy Officer with any further questions about amending your medical record.

IHE: Your information is exchanged by Information Health Exchange.

Complaints

If you believe we have violated your privacy rights, you may complain to us. You may file a complaint with us by notifying our Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services.

We support your right to protect the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

 

Medicare Shared Savings Program Accountable Care Organizations

Prism Primary Care participating in Aledade Accountable Care 16, LLC, an Accountable Care Organization (ACO). An ACO is a group of doctors, hospitals, and/or other health care providers that work together to improve the quality and experience of care you receive. ACOs receive a portion of any savings that result from reducing costs and meeting quality requirements.

• Medicare evaluates how well each ACO meets these goals every year. Those ACOs that do a good job can earn a financial bonus. ACOs that earn a bonus may use the payment to invest more in your care or share a portion directly with your providers. ACOs may owe a penalty if their care increases costs.
  
  
• Our participation in Aledade Accountable Care 16, LLC doesn’t limit your choice of health care providers. Your Medicare benefits are not changing. You still have the right to visit any doctor, hospital, or other provider that accepts Medicare at any time, just like you do now.
  
  
• To help us coordinate your health care better, Medicare shares information about your care with your providers. If you don’t want Medicare to share your health care information, call 1-800-MEDICARE (1-800-633-4227)

How do ACOs work?

• An ACO isn’t a Medicare Advantage plan which is an “all in one” alternative to Original Medicare, offered by private companies approved by Medicare. An ACO isn’t an HMO plan, or an insurance plan of any kind.
  
  
• ACOs have agreements with Medicare to be financially accountable for the quality, cost, and experience of care you receive.
  
  
• Coordinated care can avoid wasted time and costs for repeated tests and unneeded appointments. It may make it easier to spot potential problems before they become more serious – like drug interactions that can happen if one doctor isn’t aware of what another has prescribed.
  
  
• ACOs may use electronic health records, case managers, and electronic prescriptions to help you stay healthy. Some ACOs have special programs to encourage you to have a primary care visit or use their care management team. Participation in these programs is optional.

What information will be shared about me?

• Medicare shares information about your care with your health care providers; like dates and times you visited a health care provider, your medical conditions, and a list of past and current prescriptions. This information helps Aledade Accountable Care 16, LLC track the care and tests that you’ve already had.
  
  
• Sharing your data helps make sure all the providers involved in your care have access to your health information when and where they need it.
  
  
• We value your privacy. ACOs must put important safeguards in place to make sure all your health care information is safe. We respect your choice on how your health care information is used for care coordination and quality improvement. If you want Medicare to share your health care information with Aledade Accountable Care 16, LLC or other ACOs in which your health care providers participate, there’s nothing more you need to do.
  
  
• If you don’t want Medicare to share your health care information, call 1-800-MEDICARE (1-800-633-4227). Tell the representative that your health care provider is part of an ACO and you don’t want Medicare to share your health care information. TTY users should call 1-877-486-2048.
  
  
• If you change your mind and want to let Medicare share your health information again, call 1-800-MEDICARE to let Medicare know. We aren’t allowed to tell Medicare for you.
  
  
• Even if you decline to share your health care information, Medicare will still use your information for some purposes, like assessing the financial and quality of care performance of the health care providers participating in ACOs. Also, Medicare may share some of your health care information with ACOs when measuring the quality of care given by health care providers participating in those ACOs.

How can I make the most of getting care from an ACO?

• Ask your clinician if they have a secure online portal that gives you 24-hour access to your personal health information, including lab results and provider recommendations. This will help you make informed decisions about your health care, track your treatment, and monitor your health outcomes.
  
  
• As a Medicare beneficiary, you can choose or change your primary clinician or “main doctor” at any time. Your primary clinician is the health care provider that you believe is responsible for coordinating your overall care. If you choose a primary clinician, that clinician may have more tools or services to help with your care. For step-by-step instructions on how to select or change a primary clinician, or to learn more, see the Voluntary Alignment Beneficiary Fact Sheet.

What if I have concerns about being part of an ACO?

• If you have concerns about the quality of care or other services you receive from your ACO or provider, you can contact your Medicare Beneficiary Ombudsman who can assist you with Medicare-related questions, concerns, and challenges. The Medicare Beneficiary Ombudsman works closely with the Medicare program, including Medicare.gov, 1-800-MEDICARE, and State Health Insurance Assistance Programs (SHIPs), to help make sure information and assistance are available for you. Visit Medicare.gov for information on how the Medicare Beneficiary Ombudsman can help you.
  
  
• If you suspect Medicare fraud or abuse from your ACO or any Medicare provider, we encourage you to make a report by contacting the HHS Office of Inspector General (1-800-HHS-TIPS) or your local Senior Medicare Patrol (SMP).