Custom Cycle and Mobility 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 THIS NOTICE CAREFULLY.
EFFECTIVE April 14, 2003
Our Commitment to Your Privacy
Custom Cycle and Mobility is dedicated to maintaining the privacy of your
identifiable health information. In conducting our business, we will create records
regarding you and the treatment and services we provide 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 privacy practices
concerning your identifiable health information. By law, we must follow the terms of the
notice of privacy practices that we have in effect at the time.
To summarize, this notice provides you with the following information:
- How we may use and disclose your identifiable health
information
- Your privacy rights in your identifiable health information
- Our obligations concerning the use and disclosure of your
identifiable health information.
The terms of this notice apply to all records containing your
identifiable health information that are created or retained by our organization. We
reserve the right to revise or amend our notice of privacy practice. Any revision or
amendment to this notice will be effective for all of your records our organization has
created or maintained in the past, and for any of your records we may create in the
future.
If you have any questions about this notice, please contact Custom Cycle and
Mobility
We may use and disclose your information in the following ways:
- Treatment. We may use your identifiable
information to provide supplies and services to you. For example, we ask you to provide us
with such information as body weight, height , etc. Many of the people who work for us may
use or disclose your identifiable health information in order to provide supplies and
services to you or to assist others in your treatment. Additionally, we may disclose your
identifiable health information to others who may assist in your care, such as your
physician, therapists, spouse, children or parents.
- Payment. We may use and disclose your
identifiable health information in order to bill and collect payment for the services and
supplies you may receive from us. For example, we may contact your health insurer to
certify that you are eligible for benefits (and for what range of benefits), and we may
provide your insurer with details regarding your treatment to determine if your insurer
will cover, or pay for your supplies and/or services. We may also use and disclose your
identifiable health information to obtain payment from third parties that may be
responsible for such costs, such as family members. Also, we may use your identifiable
health information to bill you directly for services and supplies.
- Health Care Operations. We may use and
disclose your identifiable health information to operate our business. As examples of the
ways in which we may use and disclose your health information for our operations, may use
your health information to evaluate the quality of care you receive from us, or to conduct
cost-management and business planning activities for our business.
- Appointment Reminders. We may use and
disclose your identifiable health information to contact you and remind you of
visits/deliveries.
- Health-Related Benefits and Services. We may
use your identifiable health information to inform you of health-related benefits or
services that may be of interest to you.
- Release of Information to Family / Friends.
We may release your identifiable health information to a friend or family member that is
helping you pay for your health care, or who assists in taking care of you.
- Disclosures Required By Law. We will use and
disclose your identifiable health information when we are required to do so by federal,
state or local law.
Use and Disclosure of Your Identifiable Health Information in Certain Special
Circumstances
The following categories describe unique scenarios in which we may use or disclose your
identifiable health information:
- Public Health Risk. We may disclose your
identifiable health information to public health authorities that are authorized by law to
collect information for the purpose of:
o Maintaining vital records, such as births and deaths
o Reporting child abuse or neglect
o Preventing or controlling disease, injury or disability
o Notifying a person regarding a potential exposure to a communicable disease
o Notifying a person regarding a potential risk for spreading or contracting a disease or
condition
o Reporting reactions to drugs or problems with products or devices
o Notifying individuals if a product or device they may be using has been recalled
o Notifying appropriate government agency(ies) and authority(ies) regarding the potential
abuse or neglect of an adult patient (including domestic violence); however, we will only
disclose this information if the patient agrees or we are required or authorized by law to
disclose this information.
- Health Oversight Activities. We may disclose
your health information to a health oversight agency for activities authorized by law.
Oversight activities can include, for example, investigations, inspections, audits,
surveys, licensure and disciplinary actions; civil, administrative, and criminal
procedures or actions; or other activities necessary for the government to monitor
government programs, compliance with civil rights laws and the health care system in
general.
- Lawsuits and Similar Proceedings. We may use
and disclose your identifiable health information in response to a court or administrative
order, if you are involved in a lawsuit or similar proceeding. We also may disclose your
identifiable health in response to a discovery request, subpoena, or other lawful process
by another party involved in a dispute, but only if we have made an effort to inform you
of the request or to obtain an order protecting the information the party has requested.
- Law Enforcement. We may release identifiable
health information if asked to do so by a law enforcement official:
o Regarding a crime victim in certain situations, if we are unable to obtain the
person’s agreement
o Concerning a death we believe might have resulted from criminal conduct
o Regarding criminal conduct in our offices
o In response to a warrant, summons, court order, subpoena, or similar legal process
o To identify/locate a suspect, material witness, fugitive or missing person
o In an emergency, to report a crime (including the location or victim(s) of the crime, or
the description, identity or location of the perpetrator)
- Serious Threats to Health or Safety. We may
use and disclose your identifiable health information when necessary to reduce or prevent
a serious threat to your health and safety or the health and safety of another individual
or the public. Under these circumstances, we will only make disclosures to a person or
organization able to help prevent the threat.
- Military. We may disclose your identifiable
health information if you are a member of U.S. or foreign military forces (including
veterans) and if required by the appropriate military command facilities.
- National Security. We may disclose your
identifiable health information to federal officials for intelligence and national
security activities authorized by law. We also may disclose your identifiable health
information to federal officials in order to protect the President, other officials or
foreign heads of state, or to conduct investigations.
- Inmates. We may disclose your identifiable
health information to correctional institutions or law enforcement officials if you are an
inmate or under the custody of a law enforcement official. Disclosure for these purposes
would be necessary: (a) for the institution to provide health care services to you, (b)
for the safety and security of the institution, and/or (c) to protect your health and
safety or the health and safety of other individuals.
- Workers’ Compensation. We may release
your identifiable health information for workers’ compensation and similar programs.
- Coroners, Medical Examiners and Funeral Directors.
We may disclose health information to a coroner or medical examiner. We may also disclose
medical information to funeral directors consistent with applicable law to carry out their
duties.
- Organ Procurement Organizations. Consistent
with applicable law, We may disclose health information to organ procurement organizations
or entities engaged in the procurement, banking, or the transportation of organs for the
purpose of tissue donation and transplant.
- Research. We may disclose information to
researchers when their research has been approved by an Institutional Review Board or
Privacy Board that has reviewed the research proposal and established protocols to ensure
the privacy of your healthcare information.
Your Rights Regarding Your Identifiable Health Information
Confidential Communications.
You have the right to request that we 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. In order to request a type of confidential
communication, you must make a written request to us, specifying the requested method of
contact or location where you wish to be contacted. We will accommodate reasonable
requests. You do not need to give a reason for your request.
Requesting Restrictions. You
have the right to request a restriction in our use or disclosure of your identifiable
health information for treatment, payment or health care operations. Additionally, you
have the right to request we limit our disclosure of your identifiable health care
information to 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 identifiable health information, you must
make your request in writing to us. Your request must describe in clear and concise
fashion: (a) the information you wish restricted; (b) whether you are requesting to limit
our use, disclosure or both; and (c) to whom you want the limits to apply.
Inspection and Copies. You
have the right to inspect and obtain a copy of the identifiable health 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 to
us in order to inspect and/or obtain a copy of your identifiable health information. We
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. Reviews will be conducted
by another licensed health care professional chosen by us.
Amendment. You may ask us to
amend your health information if you believe it to be incorrect or incomplete, and you may
request an amendment for as long as the information is kept by or for us. To request an
amendment, your request must be made in and submitted to us in writing. You must provide
us with a reason that supports your request for amendment. We 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: (a) accurate and
correct; (b) not part of the identifiable health information kept by or for us; (c) not
part of the identifiable health information which you would be permitted to inspect and
copy; (d) not created by us, unless the individual or entity that created the information
is not available to amend the information.
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 disclosures we have made of
your identifiable health information. In order to obtain an accounting of disclosures, you
must submit your request in writing to our office. All requests for an “accounting of
disclosures” must state a time period which may not be longer than six years and may
not include dates before April 14, 2003. The first list you request within a 12 month
period is free of charge, but we may charge you for additional lists within the same 12
month period. We will notify you of the cost involved with additional requests, and you
may withdraw your request before you incur any costs.
Right to a Paper Copy of This Notice.
You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask
us to give you a copy of this notice at any time. To obtain a paper copy of this notice,
contact our office.
Right to File a Complaint. If
you believe your privacy rights have been violated, you may file a compliant with us or
with the Office of Civil Rights. All complaints must be in writing. You will not be
penalized for filing a complaint.
Right to Provide an Authorization for
Other Uses and Disclosures. We 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 identifiable
health information may be revoked at any time in writing. After you revoke your
authorization, we will no longer use or disclose your identifiable health information for
the reasons described in the authorization. Please note, we are required to retain records
of your care.
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