The physicians of
DOCTORS FOR WOMEN Clinic RESPECT and PROTECT
Patient Privacy. The
following guidelines have been implemented by our clinic in
accordance to
HIPAA guidelines. If
you have any questions regarding our policy, please contact our
office manager
at the phone number
below.
(318)
797-0101
Doctors For Women
8001 Youree Dr., Suite 900
Shreveport, Louisiana 71115
Notice Of Privacy Practices
As Required by the Privacy Regulations Created as a
Result of the Health Insurance Portability and Accountability Act of
1996 (HIPAA)
PLEASE REVIEW THIS NOTICE CAREFULLY.
A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy
of your individually identifiable health information (IIHI). 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 IIHI. By federal and state law, we must
follow the terms of the notice of privacy practices that we have in
effect at the time.
We realize that these laws are complicated, but we
must provide you with the following important information:
How we may use and disclose your IIHI
Your privacy rights in your IIHI
Our obligations concerning the use and disclosure of
your IIHI
The terms of this notice apply to all records
containing your IIHI that are created or retained by our practice.
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 our offices in a visible location at all times,
and you may request a copy of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE
CONTACT: Office Manager at Doctors For Women 8001 Youree Dr., Suite
320 Shreveport, Louisiana 71115.
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY
IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS
The following categories describe the different ways
in which we may use and disclose your IIHI.
1. Treatment. Our practice may use your IIHI to
treat you. For example, we may ask you to have laboratory tests
(such as blood or urine tests), and we may use the results to help us
reach a diagnosis. We might use your IIHI in order to write a
prescription for you, or we might disclose your IIHI to a pharmacy
when we order a prescription for you. Many of the people who work
for our practice &endash; including, but not limited to, our doctors
and nurses &endash; may use or disclose your IIHI in order to treat
you or to assist others in your treatment. Additionally, we may
disclose your IIHI to others who may assist in your care, such as
your spouse, children or parents.
Finally, we may also disclose your IIHI to other
health care providers for purposes related to your treatment.
2. Payment. Our practice may use and disclose your
IIHI in order to bill and collect payment for the services and items
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 treatment. We also may use and disclose your IIHI to
obtain payment from third parties that may be responsible for such
costs, such as family members. Also, we may use your IIHI to bill
you directly for services and items. We may disclose your IIHI to
other health care providers and entities to assist in their billing
and collection efforts.
3. Health Care Operations. Our practice may use
and disclose your IIHI to operate our business. As examples of the
ways in which we may use and disclose your information for our
operations, our practice may use your IIHI to evaluate the quality of
care you received from us, or to conduct cost-management and business
planning activities for our practice. We may disclose your IIHI to
other health care providers and entities to assist in their health
care operations.
OPTIONAL:
4. Appointment Reminders. Our practice may use and
disclose your IIHI to contact you and remind you of an appointment.
OPTIONAL:
5. Treatment Options. Our practice may use and
disclose your IIHI to inform you of potential treatment options or
alternatives.
OPTIONAL:
6. Health-Related Benefits and Services. Our
practice may use and disclose your IIHI to inform you of
health-related benefits or services that may be of interest to you.
OPTIONAL:
7. Release of Information to Family/Friends. Our
practice may release your IIHI to a friend or family member that is
involved in your care, or who assists in taking care of you. For
example, a parent or guardian may ask that a babysitter take their
child to the pediatrician's office for treatment of a cold. In this
example, the babysitter may have access to this child's medical
information.
8. Disclosures Required By Law. Our practice will
use and disclose your IIHI when we are required to do so by federal,
state or local law.
D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN
SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios
in which we may use or disclose your identifiable health information:
1. Public Health Risks. Our practice may disclose
your IIHI to public health authorities that are authorized by law to
collect information for the purpose of:
maintaining vital records, such as births and deaths
reporting child abuse or neglect
preventing or controlling disease, injury or
disability
notifying a person regarding potential exposure to a
communicable disease
notifying a person regarding a potential risk for
spreading or contracting a disease or condition
reporting reactions to drugs or problems with
products or devices
notifying individuals if a product or device they
may be using has been recalled
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
notifying your employer under limited circumstances
related primarily to workplace injury or illness or medical
surveillance.
2. Health Oversight Activities. Our practice may
disclose your IIHI 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.
3. Lawsuits and Similar Proceedings. Our practice
may use and disclose your IIHI in response to a court or
administrative order, if you are involved in a lawsuit or similar
proceeding. We also may disclose your IIHI in response to a
discovery request, subpoena, or other lawful process by another party
involved in the 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.
4. Law Enforcement. We may release IIHI if asked
to do so by a law enforcement official:
Regarding a crime victim in certain situations, if
we are unable to obtain the person's agreement
Concerning a death we believe has resulted from
criminal conduct
Regarding criminal conduct at our offices
In response to a warrant, summons, court order,
subpoena or similar legal process
To identify/locate a suspect, material witness,
fugitive or missing person
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)
OPTIONAL:
5. Deceased Patients. Our practice may release
IIHI to a medical examiner or coroner to identify a deceased
individual or to identify the cause of death. If necessary, we also
may release information in order for funeral directors to perform
their jobs.
OPTIONAL:
6. Organ and Tissue Donation. Our practice may
release your IIHI to organizations that handle organ, eye or tissue
procurement or transplantation, including organ donation banks, as
necessary to facilitate organ or tissue donation and transplantation
if you are an organ donor.
OPTIONAL:
7. Research. Our practice may use and disclose
your IIHI for research purposes in certain limited circumstances. We
will obtain your written authorization to use your IIHI for research
purposes except when an Institutional Review Board or Privacy Board
has determined that the waiver of your authorization satisfies the
following: (i) the use or disclosure involves no more than a minimal
risk to your privacy based on the following: (A) an adequate plan to
protect the identifiers from improper use and disclosure; (B) an
adequate plan to destroy the identifiers at the earliest opportunity
consistent with the research (unless there is a health or research
justification for retaining the identifiers or such retention is
otherwise required by law); and (C) adequate written assurances that
the PHI will not be re-used or disclosed to any other person or
entity (except as required by law) for authorized oversight of the
research study, or for other research for which the use or disclosure
would otherwise be permitted; (ii) the research could not practicably
be conducted without the waiver; and (iii) the research could not
practicably be conducted without access to and use of the PHI.
8. Serious Threats to Health or Safety. Our
practice may use and disclose your IIHI 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. Our practice may disclose your IIHI if
you are a member of U.S. or foreign military forces (including
veterans) and if required by the appropriate authorities.
10. National Security. Our practice may disclose
your IIHI to federal officials for intelligence and national security
activities authorized by law. We also may disclose your IIHI to
federal officials in order to protect the President, other officials
or foreign heads of state, or to conduct investigations.
11. Inmates. Our practice may disclose your IIHI
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.
12. Workers' Compensation. Our practice may
release your IIHI for workers' compensation and similar programs.
E. YOUR RIGHTS REGARDING YOUR IIHI
You have the following rights regarding the IIHI
that we maintain about you:
1. 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. In order to request a type of confidential communication, you
must make a written request to Office Manager at Doctors For Women
8001 Youree Dr., Suite 320 Shreveport, Louisiana 71115 specifying the
requested method of contact, or the location where you wish to be
contacted. Our practice will accommodate reasonable requests. You
do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to
request a restriction in our use or disclosure of your IIHI for
treatment, payment or health care operations. Additionally, you have
the right to request that we restrict our disclosure of your IIHI 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 IIHI, you must
make your request in writing to Office Manager at Doctors For Women
8001 Youree Dr., Suite 320 Shreveport, Louisiana 71115. 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.
3. Inspection and Copies. You have the right to
inspect and obtain a copy of the IIHI 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 Office Manager at Doctors For Women 8001 Youree
Dr., Suite 320 Shreveport, Louisiana 71115 in order to inspect and/or
obtain a copy of your IIHI. Our practice may charge a fee for the
costs of copying, mailing, labor and supplies associated with your
request. Our practice may deny your request to inspect and/or copy
in certain limited circumstances; however, you may request a review
of our denial. Another licensed health care professional chosen by us
will conduct reviews.
4. Amendment. You may ask us to amend your health
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
our practice. To request an amendment, your request must be made in
writing and submitted to Office Manager at Doctors For Women 8001
Youree Dr., Suite 320 Shreveport, Louisiana 71115. You must provide
us with a reason that supports your request for amendment. Our
practice 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 IIHI kept by
or for the practice; (c) not part of the IIHI 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.
5. 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 IIHI for non-treatment,
non-payment or non-operations purposes. Use of your IIHI as part of
the routine patient care in our practice is not required to be
documented. For example, the doctor sharing information with the
nurse; or the billing department using your information to file your
insurance claim. In order to obtain an accounting of disclosures,
you must submit your request in writing to Office Manager at Doctors
For Women 8001 Youree Dr., Suite 320 Shreveport, Louisiana 71115.
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 within the same
12-month period. Our practice will notify you of the costs involved
with additional requests, and you may withdraw your request before
you incur any costs.
6. 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 Office Manager at Doctors
For Women 8001 Youree Dr., Suite 320 Shreveport, Louisiana 71115.
7. Right to File a Complaint. If you believe your
privacy rights have been violated, you may file a complaint with our
practice or with the Secretary of the Department of Health and Human
Services. To file a complaint with our practice, contact Office
Manager at Doctors For Women 8001 Youree Dr., Suite 320 Shreveport,
Louisiana 71115. All complaints must be submitted in writing. You
will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses
and Disclosures. Our practice 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 IIHI may be revoked at any
time in writing. After you revoke your authorization, we will no
longer use or disclose your IIHI for the reasons described in the
authorization. Please note, we are required to retain records of
your care.
Again, if you have any questions regarding this
notice or our health information privacy policies, please contact
Office Manager at Doctors For Women 8001 Youree Dr., Suite 320
Shreveport, Louisiana 71115.
Doctors For Women
8001 Youree Dr., Suite 320
Shreveport, Louisiana 71115
Receipt of Notice of Privacy Practices
Written Acknowledgement Form.
I, ____________________, have received a copy of
Doctors For Women's Notice of
