FITTINGS BY MICHELE,
INC
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 THIS
INFORMATION CAREFULLY.
Understanding Your Health
Record:
A record is made each time
you visit a physician, hospital, or other health care provider. Your symptoms, examination and test
results, diagnoses, treatment, and a plan for future care are recorded. This
information is most often referred to as your “health or medical record,”
and serves as a basis for planning your care and treatment. It also serves as a means of
communication among any and all other health care professionals who may
contribute to your care.
Understanding what information is retained in your medical record and how
that information may be used will help you to ensure its accuracy, and enable
you to relate to who, what, when, where, and why others may be allowed access to
your health information. This
effort is being made to assist you in making informed decisions before
authorizing the disclosure of your medical information to
others.
Understanding Your Health
Information Rights:
Your medical record is the
physical property of the health care practitioner or facility that compiled it
but the content is about you, and therefore belongs to you. You have the right to request
restrictions on certain uses and disclosures of your information, and to request
amendments be made to your medical record.
Your rights include being able to review or obtain a paper copy of your
health information, and to be given an account of all disclosures. You may also request communications of
your health information be made by alternative means or to alternative
locations. Other than activity that
has already occurred, you may revoke any further authorizations to use or
disclose your health information.
Our
Responsibilities:
This medical practice is
required to maintain the privacy of your health information and to provide you
with notice of our legal commitment and privacy practices with respect to the
information we collect and maintain about you. This medical practice is required to
abide by the terms of this notice and to notify you if we are unable to grant
your requested restrictions or reasonable desires to communicate your health
information by alternative means or to alternative
locations.
Notice of Privacy
Practices:
This medical practice
reserves the right to change its practices and effect new provisions that
enhance the privacy standards of all patient medical information. In the event that changes are made, this
office will have an update posted.
You may request a copy be sent to you by calling our office: 410 255
0800. Other than for reasons described in this notice, this office agrees not to
use or disclose your health information without your
authorization.
To Receive Additional
Information or Report a Problem:
For further explanation of
this notice, you may contact, Michele Owens, our Medical Practice Administrator
at
410 255 0800. If you believe your privacy
rights have been violated, you have the right to file a complaint with our
Medical Practice Administrator and /or with the Secretary of Health and Human
Services with no fear of retaliation by this medical
practice.
Your health information will
be used for treatment, payment, and health care
operations:
Treatment – Information obtained by your
health care provider in this medical practice will be recorded in your medical
record and used to determine the most appropriate products and services for you.
The sharing of your health information may progress to others involved in your
care, such as physicians, other medical professionals, social workers, and
caregivers for further treatment.
Measurements and pertinent medical information may be disclosed to
manufacturers for custom garments.
Payment – Your health care information
will be used in order to receive payment for services rendered by this medical
practice. A statement may be sent
to either you or a third party payer with accompanying documentation that
identifies your diagnoses, procedures performed and products
received.
Health Care Operations –
The staff
in this medical practice will use your health information to assess the care you
received and the outcome of your case compared to others like it. Your
information may be reviewed for risk management or quality improvement purposes
in our efforts to continually improve the quality and effectiveness of the care,
products, and services we provide.
Notice of Privacy
Practices
Understanding our office
policy for specific disclosures:
Business Associates –
Some or all
of your health information may be subject to disclosure through contracts for
services to assist this medical practice in providing health care. To protect your health information, we
require these Business Associates to follow the same standards held by this
medical practice through terms detailed in a written
agreement.
Notification –
Your
medical record may be used to notify or assist family members, personal
representatives, or other persons responsible for your care to enhance your
well-being.
Communication with Family-
Using best
judgment, a family member, or close personal friend, identified by you, may be
given information relevant to your care and/or recovery.
Product Warranties –
Your name,
address, and product style and size information may be sent to manufacturers for
product warranty registration.
Marketing – This medical practice
reserves the right to contact you with information about other products,
services and other health-related benefits that may be appropriate to you. We
will also notify you of upcoming sales and events and send you notices to remind
you to schedule an appointment.
Phone Contact –
At times it
may be necessary to contact or leave a message for you regarding an appointment,
product, service or order. If you
have any restrictions as to how, where, when, what or with whom we can or cannot
leave a message please state this in the comment section at the end of this
document.
Food and Drug Administration
(FDA) – This medical practice is
required by law to disclose health information to the FDA related to any adverse
effects of food, supplements, products and product defects for surveillance to
enable product recalls, repairs, or replacements.
Worker’s Compensation –
This
medical practice will release information to the extent authorized by law in
matters of worker’s compensation.
Public Health –
This
medical practice is required by law to disclose health information to public
health and/or legal authorities charged with tracking reports of birth and
morbidity. This medical practice is
further required by law to report communicable disease, injury, or
disability.
Correctional Facilities –
This office
will release medical information on incarcerated individuals to correctional
agents or institutions for the necessary welfare of the individual. The rights outlined in this Notice of
Privacy Practices will not be extended to incarcerated
individuals.
Law Enforcement –
(1) Your
health information will be disclosed for law enforcement purposes as required
under state
law or in response to a
valid subpoena. (2) Provisions of
federal law permit the disclosure of your health information to
appropriate health oversight
agencies, public health authorities, or attorneys in the event that a staff
member or business
associate of this office
believe in good faith that there has been unlawful conduct or violations of
professional or clinical
standards that may endanger
one or more patients, worker, or the general public.
NOTICE OF PRIVACY PRACTICES
AVAILABILITY:
The terms described in this
notice will be posted where registration occurs. All individuals receiving care will be
given a hard copy.
Patient
comments:
I have received the patient
privacy policy of Fittings By Michele, Inc.
____________________________________
_________________________________
SIGNATURE OF PATIENT OR
PARENT
DATE
(IF PATIENT IS UNDER 18 YRS
OF AGE)
