PATIENT 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 READ IT CAREFULLY.
I. OUR COMMITMENT TO YOUR PRIVACY
Tri-State Rehab & Sports Center (TSRSC) is dedicated to maintaining the privacy of your medical information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your medical information. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time of your care. We will also accommodate reasonable requests you have made regarding communication of your medical information to you in a certain manner or at a certain location. We will notify you if we are unable to agree to a requested restriction.
We realize that these laws are complicated, but we must provide you with the following important information:
- Your privacy rights regarding your medical information
- How we may use and disclose your medical information
- Our obligations concerning the use and disclosure of your medical information
The terms of this notice apply to all records containing your medical information that are created or retained by TSRSC. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in a visible location at all times and on our website (tsrehab.com).
II. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding the medical information that we maintain about you:
A. Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. To request confidential communications, you must make a request in writing to Practice Administrator, 35 Kennedy Drive, Putnam, CT 06260. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
B. Inspection and Copies. You have the right to inspect and obtain a copy of the medical information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing in order to inspect and/or obtain a copy of your medical information. TSRSC may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial.
C. Amendment. You may ask us to amend your medical information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for TSRSC. To request an amendment, your request must be made in writing. You must provide us with a reason that supports your request for amendment TSRSC will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the medical information kept by or for the practice; (c) not part of the medical information which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
D. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your medical information for non-treatment or operations purposes. Use of your medical information as part of the routine patient care in our practice is not required to be documented for “accounting of disclosures”. For example, the doctor sharing medical information with your nurse in the recovery room; or the billing department using your medical information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists requested within the same 12-month period. Our practice will notify you of the costs involved with making additional requests, and you may withdraw your request before you incur any costs.
E. Right to Provide an Authorization for Other Uses and Disclosures. TSRSC will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your medical information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your medical information for the reasons described in the authorization.
F. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your medical information for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your medical information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your medical information, you must make your request in writing. Your request must describe in a clear and concise fashion:
- The information you wish restricted;
- Whether you are requesting to limit our practice’s use, disclosure or both; and
- To whom you want the limits to apply.
G. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with TSRSC or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
H. Right to Receive 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.
III. HOW WE CAN USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe the different ways that we may use and disclose your medical information.
A. Treatment. We may use medical information about you to provide you with medical treatment and services. We may disclose medical information about you to doctors, nurses, technicians, or other personnel who are involved in taking care of you.
For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to clear you for surgery. We might use your medical information in order to write a prescription for you, or we might disclose your medical information to a pharmacy when we order a prescription for you. Many of the people who work for TSRSC, including but not limited to, our doctors and physician assistants, may use or disclose your medical information in order to treat you or to assist others in your treatment. Additionally, we may disclose your medical information to others who may assist in your care, such as your spouse, children or parents.
B. Payment. We may use and disclose medical information about you so that the treatment and services you receive may be billed to you, an insurance company, or third party, in order for payment to be collected.
For example, we may need to give your insurance company information about the care you received so that the insurance company will pay us or reimburse you for the treatment.
C. Health Care Operations. We may use and disclose medical information about you for our day-to-day operations.
For example, members of the medical staff, the risk management or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will be used in a way to improve the quality and effectiveness of the healthcare and services that we provide.
D. Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for medical care.
E. Health-Related Benefits and Services. We may use and disclose medical information to inform you about health-related benefits or services that may be of interest to you.
F. Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that maybe of interest to you.
G. Individuals Involved in Your Care or Payment for Your Care. We may use and disclose medical information to a friend or family member who is involved in your care, or who assists in taking care of you.
For example, a friend may drive you to and from our facility. The friend may be given prescriptions to be filled or information necessary for your care. Therefore, some of your medical information may be shared with this person.
H. Communication Barriers. We may use and disclose medical information if your physician or another physician in the practice attempts to obtain consent, or additional information, from you but is unable to do so due to substantial communication or language barriers.
For example, your physician and/or the facility my use a foreign language or communication interpreter to aid in the communication between you and your caregivers.
A. As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law.
B. Emergency. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. However, we will only disclose the information to someone able to help prevent the threat.
C. Organ and Tissue Donation. Consistent with applicable law, we may disclose medical information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
D. Business Associates. Some of the services provided at TSRSC are provided by business associates. For example, we contract with certain laboratories to perform lab tests. When we contract for these services, we may disclose your medical information to our business associates so that they can perform the job we have hired them to do. To protect your medical information, we require our business associates to appropriately safeguard your information.
E. Workers’ Compensation. We may release medical information about you to the extent authorized by and to the extent necessary to comply with the laws relating to workers’ compensation or other similar programs established by law.
F. Public Oversight Activities. As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
G. Health Oversight Activities. We may disclose medical 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.
H. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in a dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
I. Law Enforcement. We may disclose medical information for law enforcement purposes as required by law or in response to a valid subpoena.
J. Food and Drug Administration. We may disclose to the FDA medical information related to adverse events with respect to food, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
K. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.
L. Victims of Abuse, Neglect or Domestic Violence. We may release medical information to a government authority if we reasonably believe that you are a victim of abuse, neglect or domestic violence, to the extent authorized or required by law.
M. Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
- to prevent or control disease, injury or disability;
- to report births and deaths;
- to report child abuse or neglect;
- to report reactions to medications or problems with products;
- to notify people of recalls of products they may be using;
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
N. Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
V. OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only upon specific written authorization you provide to us. This allows TSRSC to use your medical information for the purpose listed in that authorization document. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. The revocation, however, will not have any effect on any action TSRSC took before it received the revocation.
VI. QUESTIONS OR COMPLAINTS
If you have questions or requests for additional information, you may contact our privacy officer at the address below.
If you believe your privacy rights have been violated, you can submit a written complaint describing the circumstances surrounding the violation to:
35 Kennedy Drive
Putnam, CT 06260
To request a written copy of this notice write to the address above or call the Main Office: 860-963-2133 or write to the Secretary of Health and Human Services in Washington, D.C. You will not be penalized for filing any complaint.