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.
If you have any questions about this Notice of Privacy Practices, please contact the Alliance Privacy Official at (949) 242-5854(949) 242-5854 or via e-mail sent to email@example.com.
Alliance HealthCare Services, Inc., its subsidiaries and affiliates (collectively, “Alliance”) is required by law to maintain the privacy of your protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. We are also required to comply with this Notice of Privacy Practices. We may change its terms in the future, and the revised notice will then be effective for all Protected Health Information maintained on or after that date. Our current Notice of Privacy Practices is posted on our Web site – www.alliancehealthcareservices-us.com. You may obtain a copy at your next appointment, or you may ask our Privacy Official to send a printed copy to you.
“Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future health care related services. This Notice of Privacy Practices describes how Alliance may use and disclose your Protected Health Information for treatment, payment and health care operations. It also discusses other purposes permitted or required by law. Additionally, this Notice describes your rights of access and control of your Protected Health Information.
Uses and Disclosures of Your Protected Health Information
Permitted routine uses and disclosures for treatment, payment and health care operations:
Your Protected Health Information will be used and disclosed to support your care and treatment, to ensure that we will receive payment for charges, and to support our administrative operations.
Descriptions and examples of these permitted routine uses and disclosures include:
Treatment: We will use and disclose your Protected Health Information so that we can provide services to you and to allow us to work with others assisting us with your care. For example, we may disclose your Protected Health Information to your physicians to give them information necessary to diagnose and treat your condition. We may also disclose your Protected Health Information to others, such as pharmacy, medical record and radiology entities, as necessary.
Payment: We will use your Protected Health Information so that we can obtain payment for our services. Your insurance carrier may require us to disclose your Protected Health Information before and/or after services are provided to you. This may include determination of eligibility, verification of your insurance benefits, determination of medical necessity, pre-authorization and insurance billing.
Health care operations: We will use your Protected Health Information for the effective and efficient delivery of services to you. This includes quality assessment, employee training, support and maintenance of our equipment and systems, organization accreditation, and coordination with our business partners and suppliers.
Specifically, we may disclose your Protected Health Information to the facility where you are obtaining your services to allow the local storage of scan films and/or patient records. Before your appointment, we may contact you by telephone to confirm its time and location. At the time of your appointment, you may be asked to “sign in,” and we may call you by name when it is time for you to be seen.
We may also share your Protected Health Information with third-party “business associates” that perform certain activities (e.g., billing, transcription services, billing and collections, etc.) on our behalf. In these instances, Alliance will have written agreements in place to protect the privacy of your Protected Health Information.
Possible uses and disclosures for which you do not have an opportunity to object:
There are also some circumstances that require Alliance to use or disclose your Protected Health Information. We must do so without your authorization, and you will not have the opportunity to object.
General situations include:
When required by law: We may use or disclose your Protected Health Information to the limited extent required by law. You will be notified, if required by law, of any such uses or disclosures.
To demonstrate our compliance: The U.S. Department of Health and Human Services or other regulatory agency may require us to disclose your Protected Health Information so that we can demonstrate our compliance with laws or if non-compliance is suspected.
Specific situations include:
Abuse or neglect: Consistent with applicable federal and state laws, we may provide your Protected Health Information to a public health, civil authority or government agency when child abuse, neglect or domestic violence may have occurred if: 1) a law requires the disclosure, 2) you agree to the disclosure, 3) a law allows the disclosure and the disclosure is needed to prevent potential serious harm to you or someone else, or 4) a law allows the disclosure, you are unable to agree or disagree, the information is needed for immediate action, and the information will not be used against you.
Criminal activity: We may disclose your Protected Health Information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
Law enforcement: We may disclose Protected Health Information for law enforcement purposes. These purposes include: 1) limited information requests for suspect identification and location, 2) identifying victims or researching victims of a crime, 3) suspicion of criminal conduct related to a death, 4) investigation of a crime that occurred on our premises, and 5) when a medical emergency has occurred off of our premises and it is likely that a crime has been committed.
Legal proceedings: We may disclose Protected Health Information in judicial or administrative proceedings, in response to a court order or administrative hearing (if expressly authorized), and, in certain conditions, in response to a subpoena, discovery request or other lawful process.
Public health: We may disclose your Protected Health Information to a public health authority for public health activities such as controlling disease, injury or disability.
Communicable diseases: We may disclose your Protected Health Information to a person who may have been exposed to certain communicable diseases or may be at risk of contracting or spreading the disease or condition.
Health oversight: We may disclose Protected Health Information to health oversight, regulatory and accreditation agencies for purposes such as audits, investigations and inspections.
Food and drug administration: We may disclose your Protected Health Information as required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products (to enable product recalls, repairs or replacements), or to perform oversight activities.
Inmates: If you are in custody, we may disclose your Protected Health Information to your correctional facility or to law enforcement entities related to your care, to ensure the health and safety of others related to your custody or institution, or to maintain the safety, security, law and order of the facility.
Workers’ compensation: We may disclose your Protected Health Information to comply with workers’ compensation laws and other similar programs.
National security and military activities: We may disclose your Protected Health Information to federal officials authorized to conduct national security and intelligence activities. If you are in the Armed Forces, we may disclose your Protected Health Information 1) for activities deemed necessary by command authorities, 2) for benefits eligibility determination by the Department of Veterans Affairs, or 3) to a foreign military authority (if you are a member of their military services).
Possible uses and disclosures for which you may object:
If the use or disclosure of your Protected Health Information is not routinely permitted or legally required, you may have the opportunity to impose limitations on its use and disclosure.
Specifically, you may limit:
Disclosure to family members, relatives or personal representatives: Unless you request limitations, we may disclose your Protected Health Information to members of your immediate family, other relatives, or your legally designated health care decision maker. We will limit disclosures to information directly related to their involvement in your health care. You may prevent this disclosure, or you may seek to limit it. You may also designate someone other than those listed above (such as a close personal friend) to whom we may disclose your Protected Health Information.
If you are physically unable to express your objection or limitation, we will proceed as noted above if we believe that doing so is in your best interest. If a family member, relative or personal representative is not present, we may use your Protected Health Information to identify a representative. In the case of emergencies and disasters, we may disclose your Protected Health Information to authorized entities assisting in response and relief efforts.
Uses and disclosures permitted only with your written authorization:
In situations not covered above, use or disclosure of your Protected Health Information will occur only with your written authorization. These cases include requests you make to Alliance, as well as those we may receive from third parties. For example, you may request that we disclose some or all of your Protected Health Information to an attorney, consultant or personal acquaintance. Similarly, Alliance may receive a request from a third party to disclose your Protected Health Information.
Further, certain federal and state laws require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your Protected Health Information that: 1) is maintained in psychotherapy notes; 2) is about mental health and developmental disabilities services; 3) is about alcohol and drug abuse prevention and treatment; 4) is about HIV/AIDS testing, diagnosis or treatment; 5) is about communicable disease(s); 6) is about genetic testing; or 7) is about sexual assault. In order for us to disclose your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written authorization.
You may later revoke your authorization, in writing, if you change your mind. Should you change your mind, your revocation will only be effective to the extent we have not previously relied on your revocation in making disclosures of your protected health information.
These are your privacy rights and how you can exercise them:
You have the right to obtain a printed copy of this Notice. You may obtain a copy of this Notice at the time of your appointment, or you may contact our Privacy Official at any time to request that a copy be sent to you.
You have the right to inspect and copy your Protected Health Information. You may review and receive a copy of your Protected Health Information contained in our Designated Record Set for as long as we maintain the records. A “Designated Record Set” contains medical, billing and any other records that Alliance uses for making clinical and financial decisions about you.
Requests to inspect or obtain your records must be submitted in writing on a record request form to our Privacy Official. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. We will provide you with a copy of any of your Protected Health Information that we maintain in an electronic health record. The copy we provide will be in an electronic format and, if you provide us with clear, conspicuous and specific directions, we will send the information directly to another person of your choosing. We may charge you a reasonable cost-based fee for any requested copies.
You have the right to request that we amend your Protected Health Information. Should you disagree with any Protected Heath Information maintained in our Designated Record Set, you may request, in writing to our Privacy Official, that we change it for as long as we maintain it. Alliance is not required to make the changes you request. If your request is denied, you have the right to file a statement of disagreement with our Privacy Official and we may prepare a rebuttal. You will be provided with a copy of any rebuttal; copies of related correspondence will be included with your Protected Health Information.
You have the right to request how we provide confidential communications to you. You may request special handling for communication of confidential matters. All such requests must be submitted in writing to our Privacy Official. Alliance will accommodate reasonable requests, and we will not require you to provide a reason or explanation for your request. We may, as a condition for our agreement, require you to provide additional contact information or other assurances regarding payment of your health care charges.
You have the right to request restrictions relating to your Protected Health Information. You may request restrictions on the use or disclosure of your Protected Health Information. Requests must be in writing and specify: 1) the specific restriction requested and 2) to whom you wish it to apply. Before and during your appointment, you may make the request to any Alliance employee you contact. After your appointment, restriction requests must be forwarded to our Privacy Official.
Alliance is not required to agree to all restriction requests. If we agree to the restriction, we will not use or disclose your Protected Health Information in violation of the restriction unless it is necessary to provide emergency treatment to you. The restriction will take effect after it has been approved.
Upon your written request, and except as otherwise required by law, Alliance will restrict disclosures of Protected Information to health plans for purposes of carrying out payment or health care operations (but not for purposes of carrying out treatment) so long as the Protected Heath Information pertains solely to a health care item or service for which Alliance has been paid out of pocket in full.
You have the right to receive an accounting of certain disclosures we have made, if any, of your Protected Health Information. Your request must be submitted in writing to our Privacy Official. The accounting excludes disclosures for treatment, payment or health care operations as described in this Notice. It also excludes disclosures we may have made to you, your family members or designated representatives. Other exceptions, restrictions and limitations may also apply. The accounting will cover a maximum period of six years. You may request a shorter time period for the accounting. After the first request for an accounting within a 12-month period, we may charge you a reasonable cost-based fee.
If you believe that your privacy rights have been violated, you may file a complaint with either Alliance or with the Secretary of the U.S. Department of Health and Human Services. Alliance supports your right to file a complaint and will not take any adverse action against you for doing so.
To file a complaint with Alliance or for additional information about the complaint process, contact the Alliance Privacy Official at (949) 242-5854(949) 242-5854 or via e-mail sent to firstname.lastname@example.org.
To file a complaint with the Secretary of the U.S. Department of Health and Human Services, contact:
Office for Civil Rights
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
This Notice is published and effective on January 18, 2010.