Southern Family Medicine, LLC
NOTICE OF PRIVACY PRACTICES
Effective September 13, 2004
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have questions about this Notice, contact our Privacy Officer:
Amy B. Pedone, M.D.
Southern Family Medicine, LLC
16324 Mount Airy Road
Shrewsbury, PA 17361
We are required by law to maintain the
privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with
respect to protected health information. We are required to abide by the terms of this Notice.
We reserve the right
to change this Notice at any time. We also reserve the right to make any change effective for all protected health information
that we maintain at the time of the change - including information that we created or received prior to the effective date of the
change. The current version of this Notice will be on our web site at www.southernfamilymed.com.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose your medical information. For each category of uses or
disclosures, we will give some examples. Not every use or disclosure in a category will be listed.
a. For Treatment. We will use medical information about you to
provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians,
medical students, or other office personnel who are involved in taking care of you. For example, we would disclose your health
information, as necessary, to a home health agency that provides care to you. We also may disclose medical information about you
to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
b. For Payment. We will use and disclose medical information
about you so that the treatment and services we provide may be billed to and payment may be collected from you, an insurance
company, a governmental entity such as Medicare, or a third party. For example, we may need to give your health plan information
about treatment we provide so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan
about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment or
hospital admission. We may also have to send your information to more than one health plan in circumstances where it is not clear
which health plan has the responsibility to pay for your care.
c. For Healthcare Operations. We will use and disclose medical
information about you for our operations. These uses and disclosures are necessary to run our office and make sure that all of our
patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate
the performance of our staff in caring for you. We may also combine medical information about many patients to decide what
additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also
disclose information to doctors, nurses, technicians, medical students, and other office personnel for review and learning purposes.
We may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may
also call you by name in the waiting room when your physician is ready to see you.
d. Treatment Alternatives. We may/will use and disclose your
medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
e. Health-Related Benefits/Services. We may use and disclose your
medical information to tell you about health-related benefits or services that may be of interest to you.
f. Reminders. We may/will use and disclose medical information
about you to contact you in an effort to provide appointment reminders.
g. Research. Under certain circumstances, we will use and disclose
medical information about you for research purposes. For example, a research project may involve comparing the health and recovery
of all patients who received one medication to those who received another for the same condition. All research projects are
subject to a special approval process that takes into account patients’ need for privacy.
h. Business Associates. We contract with business associates to
provide some services, such as medical billing and transcription services. When these services are contracted, we may/will
disclose your health information to our business associate so that they may perform the job we have asked them to do. To protect
your health information however, we require the business associate to appropriately safeguard your information.
i. As Required By Law. We will disclose medical information
about you when required to do so by federal, state, or local law.
j. To Avert a Serious Threat to Health / Safety. We will 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.
k. Individuals Involved in Your Care or Payment for Your Care. We
may release medical information about you to a friend or family member who is involved in your medical care. We may also give
information to someone who helps pay for your care. Except in emergency situations, you may object to the uses and disclosures
described in this Section k, either in general or to any specific person or persons to whom your medical information might
otherwise be disclosed.
l. Special Situations. We will use and disclose medical information
• To facilitate organ and tissue donation.
• For specialized governmental functions, including the military and veterans, criminal corrections and public benefit purposes.
• For Workers’ Compensation or similar programs, as permitted by law.
• For public health activities.
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.
• For health oversight activities including, for example, audits, investigations and licensure.
• For lawsuits and disputes, we will disclose medical information about you in response to a valid court or administrative order or in the course of defending ourselves.
• For law enforcement purposes.
• To coroners, medical examiners, and funeral directors as necessary to assist them.
m. Written Authorization. Except as described above, we will
disclose your medical information only with your prior written authorization. You may revoke that authorization, in writing, at
any time, unless we have taken action relying on your prior authorization or if you signed the authorization as a condition of
obtaining insurance coverage.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:
a. Right to Inspect and Copy. You have the right to inspect and
copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records,
but does not include psychotherapy notes and other mental health records under certain circumstances.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to
our Privacy Officer. 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 to inspect and copy medical information in certain very limited circumstances, including requests by an
inmate at a correctional institution, requests for information we obtained from someone else subject to certain confidentiality
agreements, and some requests concerning ongoing research projects. If you are denied access to medical information for any other
reason, you may request that the denial be reviewed. Another licensed healthcare professional chosen by us will review your
request and the denial. The person conducting the review will not be the person who denied your request. We will comply with
the outcome of the review.
b. Request to Amend. If you feel that medical information we
have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, please submit a
written request to our Privacy Officer with a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may
also deny your request if you ask us to amend information that: (i) was not created by us, unless the person or entity that
created the information is no longer available to make the amendment; (ii) Is not part of the medical information kept by us;
(iii) is not part of the information that you would be permitted to inspect and copy; or (iv) is accurate and complete.
If we deny your request, you may submit a written statement disagreeing with the denial. We will keep the statement and include
it with future disclosures of the information to which it relates.
c. Right to an Accounting of Disclosures. You have the right to
request an "accounting of disclosures." This is a list of the disclosures of medical information about you, with exceptions. We
do not need to account for disclosures made: (i) to you; (ii) pursuant to your written authorization; (iii) for the purpose of
carrying out treatment, payment or operations; (iv) to persons involved in your care, or to notify your family or friends about
your whereabouts; (v) that are incidental to another permissible use or disclosure; (vi) for national security or intelligence
purposes; (vii) to correctional institutions or law enforcement officers who had you in custody at the time of the disclosure;
(viii) as part of a limited data set; or (ix) to a health oversight agency or law enforcement official if they so request. The
accounting will include the date of each disclosure, the name of the person/entity to whom disclosure was made, and a brief
description of the information disclosed together with the purpose of the disclosure.
To request this list or accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request
must state a time period that may not be longer than six years and may not include dates before September 13, 2004. Your request
should indicate in what form you want the list (for example: on paper, electronically). The first list you request within a
12-month period will be free. For additional lists, we may charge you. 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.
d. 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 healthcare
operations. You also have the right to request a limit on the medical information we disclose about you to someone who is
involved in your care or the payment for your care, like a family member or friend.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed
to provide you emergency treatment. To request restrictions, you must make your request in writing to our Privacy Officer. In
your request, you must tell us (i) what information you want to limit; (ii) whether you want to limit our use, disclosure, or
both; and (iii) to whom you want the limits to apply, for example, disclosures to your spouse.
e. Right to Confidential Communications. You have the right to
request to receive communications from us on a confidential basis by using alternative means for receipt of information or by
receiving the information at alternative locations. All reasonable requests will be granted. Contact our Privacy Officer if you
require such confidential communications.
f. Right to a Paper Copy of This Notice. You have the right to
a paper copy of this notice by requesting a paper copy from our Privacy Officer in writing.
If you believe your privacy rights have
been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a
complaint with us, contact our Privacy Officer:
Amy B. Pedone, M.D.
All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Southern Family Medicine, LLC
16324 Mount Airy Road
Shrewsbury, PA 17361