Effective 2/7/05
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact Tammy L. Belcher, MS, OTR/L.
WHO WILL FOLLOW THIS NOTICE:
This notice describes Giant Leaps Occupational Therapy's practices and that of all employees, staff and other office personnel.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about your child and his/her health is personal. We are committed to protecting the privacy of this information. We create a record of the care and services your child receives at this office. We need this record to provide your child with quality care and to comply with certain legal requirements. This notice applies to all of the records of your child’s care generated by this practice. This notice will tell you about the ways in which we may use and disclose medical information about your child. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
- Make sure that medical information that identifies your child is kept private
- Give you this notice of our legal duties and privacy practices with respect to medical information about your child, and
- Follow the terms of the notice that are currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION
ABOUT YOUR CHILD:
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean. Not every use or disclosures in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment. We may use medical information about your child to provide him/her with medical treatment and services. We may disclose medical information about your child to therapists, occupational therapy students or other personnel who are involved in taking care of your child at the practice. We may also disclose medical information to your child’s prescribing physician.
For Payment. We may use and disclose medical information about your child so the treatment and services your child receives at the practice may be billed to and payment collected from you or a third party. This may also include the disclosure of medical information to obtain prior authorization for treatment and procedures from your insurance plan.
Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment.
Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Individuals Involved in Your Child’s Care or Payment for Your Child’s Care. We may release medical information about your child to a friend or family member who is involved in your child’s medical care. We may also give information to someone who helps pay for your child’s care.
As Required by Law. We will disclose medical information about your child when required to do so by federal, state or local law.
Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include 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 and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about your child in response to a court or administrative order.
Law Enforcement. We may disclose medical information if asked to do so by law enforcement officials:
- In response to a court order, subpoena, warrant, summons or similar process.
Research . We may disclose information to researchers when an institutional review board has reviewed the research proposal, and established protocols to ensure the privacy of your child’s health information.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOUR CHILD:
You have the following rights regarding medical information we maintain about your child:
Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your child’s care. Usually, this includes medical and billing records. To inspect and copy medical information that may be used to make decisions about your child, you must submit your request in writing to Tammy Belcher, MS, OTR/L. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will abide by the outcome of the review.
Right to Amend. If you feel the medical information we have about your child is incorrect or incomplete, you may ask us to amend the information. You have the right to request and amendment for as long as the information is kept by the practice. To request and amendment, your request must be in writing and submitted to Tammy L. Belcher, MS, OTR/L. In addition, you must provide a reason that supports your request. We may deny your request for and amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us.
- Is not part of the information kept by the practice.
- Is not part of the information which you would be permitted to inspect and copy.
- Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures". This is a list of the disclosures we made of medical information about your child. To request this list of accounting, you must submit your request in writing to Tammy L. Belcher, MS, OTR/L. Your request must state a time period, which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about your child to someone who is involved in your care or the payment for your child’s care, like a family member or friend.
WE ARE NOT REQUIRED TO AGREE TO YOUR REQUEST.
To request restrictions, you must make your request in writing to Tammy L. Belcher, MS, OTR/L. In your request, you must tell us what information you want to limit, whether you want us to limit our use, disclosure or both and to whom you want the limits to apply.
Right to Request Confidential Communications. 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 at home, not at work or at work and not at home. To request confidential communications, you must make your request in writing to Tammy L. Belcher, MS, OTR/L. We will not ask the reason for your request. We will accommodate all reasonable requests. Your request must specify how and where you wish to be contacted.
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. To obtain a copy of this notice, you must make your request in writing to Tammy L. Belcher, MS, OTR/L.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about your child as well as any information we receive in the future. We will have a copy of the current notice in the practice waiting room.
COMPLAINTS:
If you believe your privacy rights have been violated, you may file a complaint with the practice or the Secretary of the Department of Health and Human Services. The complaint to the practice must be submitted in writing to Tammy L. Belcher, MS, OTR/L.
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 with your written permission. If you provide us permission to use or disclose medical information about your child, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about your child for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to your child.
