Your medical & financial records

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.

Like everything else in the fast moving and legalistic world we live in, the practice of medicine today is much more complicated than it used to be. Part of what that means to you as a patient is that the records the clinic keeps of your visits here are often used in new ways. We are providing you with this information as a requirement of the Health Insurance Portability and Accountability Act of 1996, but we are also happy for the opportunity to share our feelings about the responsibility we feel toward you and the private information with which you have entrusted us.

While the records belong to the clinic, you have a right to know what is in them. If you need a copy of some portion of your medical or financial records simply ask the receptionist for it.

The primary use for your medical record remains to help your health care provider keep track of your health history including all the symptoms that have brought you to the clinic, your family health history, examination and test results, diagnoses made, treatments supplied, and medications given.

We might use your medical records in the following say:

• They might be sent to another doctor or therapist who we are asking to join us in your care. In this case, we would ask you to sign a consent form and would only be sending that part of your file that relates directly to the condition for which we refer.

• We might use them as part of our quality assessment program in which we review the care our patients receive to be sure that we are documenting well and that each provider is rendering high quality care.

• Our billing clerks might read a certain day's progress notes to decide how best to enter codes into a bill to your insurance company.

• We might send a copy of a course of treatment to an insurer who asks us to send records that support a bill we have sent them for your care. We ask you to authorize that by signing a form when you first sign up as a new patient.

• Sometimes the law requires us to divulge medical records. In medical malpractice cases or criminal cases where treatment might be related to injuries during a crime the court might subpoena the medical records of patients involved. Another case like this is when we are required to divulge knowledge or suspicion of abuse.

· Your records might also be seen by business associates whom we hire to do such things as help us devise better record systems, store our records electronically, train our billing staff or other jobs related to efficient operation of the clinic. To protect your privacy in these cases, we require all of our business associates to demonstrate that they comply with our confidentiality requirements and to sign an agreement that limits what they can do with the records.

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The primary use for any financial records we keep is to help us remember how much is owed and whether the bill goes to you, an insurance company, or a public health care payer. Uses to which those records might be put include:

• Insurers sometimes ask for copies of records of payment for a certain service, so we would send them that segment of your payment records to them to support the billing.

• Our accounts receivable department might see an amount due in your account when performing monthly jobs like balancing or aging accounts receivable or performing collection duties.

· If we were to change financial management software programs or needed to refer an account for collections, a business associate might have to read your account in order to deal with it effectively. Business associates sign agreements assuring confidentiality.

Our staff is trained to protect the privacy of your medical records and financial information. They are also trained to understand that any breach of confidentiality is grounds for termination from their jobs. If you have any reason to believe that any member of our staff has violated this sacred trust, please ask to see the privacy officer so that we can act appropriately. Even though the medical practice and not the patient is the owner of the medical record, we want to use the contents of that record only in appropriate ways acceptable to you. If you would like to place any restrictions on the way we use your records, please complete the form below and give it to the receptionist when you visit or mail it to our office. While the law does not require us to abide by such restrictions, we pledge to do our best to do so.

Thank you for taking the time to read this and thank you, too, for selecting us as your health care provider. If you have any questions about this information or any other aspect of your care here, please feel free to ask the receptionist. She will either answer your question or refer you to the person in the clinic most qualified to answer it.

Please restrict the use of my medical and/or financial records in the following way:

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Signed: ________________________________