HIPAA NOTICE OF PRIVACY PRACTICES

Hattiesburg Clinic P.A.

Effective Date: September 23, 2013

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

If you have any questions about this notice, please contact the Privacy Officer at (601) 264-6000.

WHO WILL FOLLOW THIS NOTICE:

  • Hattiesburg Clinic P.A.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

Hattiesburg Clinic, P.A. is dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. Hattiesburg Clinic, P.A. is required by law to abide by the terms of this Notice.

OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements.This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

Much of your information is stored electronically, rather than being in paper form. When we use or disclose your protected health information in the ways described in this notice, we may do so by providing printed copies of your health information or by allowing the authorized person or persons to access the electronic record. However, whether your health information is in paper or electronic form, we will handle it in compliance with the provisions of this notice.

We are required by law to:

  • make sure that health information that identifies you is kept private;
  • give you this Notice of our legal duties and privacy practices with respect to health information about you;
  • notify you following a breach of your unsecured protected health information; and
  • follow the terms of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose health information.

For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will belisted. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment.

We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors,nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices, at the hospital if you arehospitalized under our supervision, or at another doctor's office, lab, pharmacy, or other health care provider to whom we may refer you for consultation,to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. For example, a doctor treating you for a broken legmay need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian at the hospitalif you have diabetes so that we can arrange for appropriate meals. We may also disclose health information about you to an entity assisting in a disasterrelief effort so that your family can be notified about your condition, status and location. We may and often do make your records available to medicalpersonnel at other facilities who are providing care and treatment to you, so that they will be aware of your complete medical history as reflected in ourmedical records system. For example, Forrest General Hospital shares our medical record system and has access to your Hattiesburg Clinic records when youare a patient of the hospital.

For Payment:

We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected fromyou, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so your health plan willpay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or todetermine whether your plan will cover the treatment.

For Health Care Operations:

We may use and disclose health information about you for operations of our health care practice. These uses and disclosures are necessary to run ourpractice and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services andto evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional serviceswe should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where wecan make improvements. We may remove information that identifies you from this set of health information so others may use it to study health care deliverywithout learning who our specific patients are.

Research.

Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involvecomparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects,however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balancethe research needs with patients' need for privacy of their health information. Before we use or disclose health information for research, the project willhave been approved through this research approval process; but we may disclose health information about you to people preparing to conduct a researchproject. For example, we may help potential researchers look for patients with specific health needs, so long as the health information they review doesnot leave our facility. We will almost always ask for your specific permission if the researcher will have access to your name, address, or otherinformation that reveals who you are, or will be involved in your care.

Organ and Tissue Donation.

If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or toan organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

As Required By Law.

We will disclose health information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety.

We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of thepublic or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Military and Veterans.

If you are a member of the armed forces or separated/discharged from military services, we may release health information about you as required by militarycommand authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel tothe appropriate foreign military authorities.

Workers' Compensation.

We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries orillness.

Public Health Risks.

We may disclose health information about you for public health activities.

These activities generally include the following:

  • to prevent or control disease, injury or disability;
  • to report births and deaths;
  • to report child abuse or neglect;
  • to report reactions to medications or problems with products;
  • to notify people of recalls of products they may be using;
  • to notify a person or organization required to receive information on FDA-regulated products;
  • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only makethis disclosure if you agree or when required or authorized by law.

Health Oversight Activities.

We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits,investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, andcompliance with civil rights laws.

Lawsuits and Disputes.

If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may alsodisclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, butonly if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement.

We may release health information if asked to do so by a law enforcement official:

  • in reporting certain injuries, as required by law, gunshot wounds, burns, injuries to perpetrators of crime;
  • in response to a court order, subpoena, warrant, summons or similar process;
  • to identify or locate a suspect, fugitive, material witness, or missing person:
  • about the victim of a crime, if the victim agrees to disclosure or under certain limited circumstances, we are unable to obtain the person's agreement;
  • about a death we believe may be the result of criminal conduct;
  • about criminal conduct at our facility; and
  • in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person whocommitted the crime.

Coroners, Health Examiners and Funeral Directors.

We may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the causeof death. We may also release health information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities.

We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activitiesauthorized by law.

Protective Services for the President and Others.

We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons orforeign heads of state or conduct special investigations.

Inmates.

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to thecorrectional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) toprotect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU.

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy:

You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billingrecords. This does not include psychotherapy notes.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer. If yourequest a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request thatthe denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person conducting thereview will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend.

If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request anamendment for as long as we keep the information. To request an amendment, your request must be made in writing, submitted to the Director of HealthInformation Services, and must be contained on one page of paper legibly handwritten or typed in at least 10 point font size. In addition, you must providea reason that supports your request for an amendment.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny yourrequest if you ask us to amend information that:

  • was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • is not part of the health information kept by or for our practice; is not part of the information which you would be permitted to inspect and copy; or
  • is accurate and complete.

Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures.

You have the right to request an accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment,payment, and health care operations, as previously described. To request this list of disclosures, you must submit your request in writing to the Directorof Health Information Services. Your request 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 will be free. For additional lists, we may charge you for the costs of providing the list. Wewill notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you alist of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by whatdate we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.

Right to Request Restrictions.

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health careoperations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or thepayment for your care, such as a family member or friend. For example, you could ask that we restrict a specified nurse from use of your information, orthat we not disclose information to your spouse about a surgery you had.We are not generally required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it willnegatively impact the care we may provide you.We are required to comply with requests to restrict uses and disclosures of your medical information to a health plan if the purpose for the disclosure isnot related to treatment and the health care services to which the medical information applies have been paid out-of-pocket in full. If we do agree, wewill comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request inwriting to the Privacy Officer. In your request, you must tell us what information you want to limit and to whom you want the limits to apply; for example,use of any information by a specified nurse, or disclosure of specified surgery to your spouse.

Right to Request Confidential Communications.

You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that weonly contact you at work or by mail to a post office box. To request confidential communications, you must make your request in writing to the PrivacyOfficer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish tobe contacted.

Right to a Paper Copy of This Notice.

You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from the manager of the medical department,Privacy Officer, or from our website, www.hattiesburgclinic.com.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already haveabout you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain on thefirst page, in the top center, the effective date. In addition, each time you register for treatment or health care services, we will offer you a copy ofthe current notice in effect if not previously provided to you.

COMPLAINTS

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 HumanServices. To file a complaint with us, contact the Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION.

With limited exceptions, we are required to obtain your permission before using or disclosing your health information contained in psychotherapy notes, formarketing purposes, or in transactions for the sale of your health information. Other uses and disclosures of health information not covered by this noticeor the laws that apply to us will be made only with your written permission, If you provide us permission to use or disclose health information about you,you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you forthe reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with yourpermission, and that we are required to retain our records of the care that we provided to you.

Acknowledgement of Receipt of this Notice

We will request that you sign a separate form or notice acknowledging you have received a copy of this notice. If you choose, or are not able to sign, astaff member will sign their name, date. This acknowledgement will be filed with Clinic records.


ACKNOWLEDGMENT

I hereby acknowledge that I have received and had an opportunity to ask questions concerning Hattiesburg Clinic, P.A.’s Notice of Privacy Practices.

___________________________________________________ __________________

Patient or Patient’s Representative Date

Office Use Only

Label


________________________________

Patient’s Medical Record Number

________________________________

Representative’s Relationship to Patient





FORREST GENERAL HOSPITAL

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Forrest General Hospital is dedicated to protecting your medical information. We are required by law to maintain the privacy of your medical information and to provide you with this notice of our legal duties and privacy practices with respect to your medical information. Forrest General Hospital is required by law to abide by the terms of this notice.

HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED:

We will use and disclose your medical information as part of rendering patient care for treatment, payment or health care operations purposes. For example, your medical information may be used by the doctor or nurse treating you, by the business office to process your payment for the services rendered and by administrative personnel reviewing the quality of the care you receive. We may and often do make your records available to medical personnel at other facilities who are providing care and treatment to you, so that they will be aware of your complete medical history as reflected in our medical records system. For example, the Hattiesburg Clinic shares our medical record system and has access to your Forrest General records when you are a patient of that clinic.

Much of your health information is stored electronically, rather than being in paper form. When we use or disclose your protected health information in the ways described in this notice, we may do so by providing printed copies of your health information or by allowing the authorized person or persons to access the electronic record. However, whether your health information is in paper or electronic form, we will handle it in compliance with the provisions of this notice.

We may also use and/or disclose your medical information in accordance with federal and state laws for the following purposes:

Appointment Reminders:

We may contact you to provide appointment reminders.

Treatment Information:

We may contact you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fund Raising

We may contact you to raise funds for the Forrest General Healthcare Foundation. You have the right to opt-out of such fundraising activities by notifying us in writing.

Disclosure to Department of Health and Human Services

We may disclose your medical information when required by the United States Department of Health and Human Services as part of an investigation or determination of our compliance with relevant laws.

Facility Directory

Unless you object, and with the exception of behavioral health patients, we will include your name, location in the hospital, your condition described in general terms and your religious affiliation in our directory of individuals. The directory information, except for your religious affiliation, will be released to people who ask for you by name. Your religious affiliation may be given to members of the clergy, even if they do not ask for you by name, unless you object.

Family and Friends:

Unless you object, we may disclose your medical information to family members, other relatives or close personal friends when the medical information is directly relevant to that person’s involvement with your care.

Notification:

Unless you object, we may use or disclose your medical information to notify a family member, a personal representative or another person responsible for your care, general condition or death.

Disaster Relief:

We may disclose your medical information to a public or private entity, such as the American Red Cross, for the purpose of coordinating with that entity to assist in disaster relief efforts.

Public Health Activities:

We may use or disclose your medical information for public health activities, including the reporting of disease, injury, vital events and the conduct of public health surveillance, investigation and/or intervention.

Health Oversight Activites:

We may disclose your medical information to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions, administrative and/or legal proceedings.

Abuse or Neglect:

We may disclose your medical information when it concerns abuse, neglect or violence to you in accordance with federal and state law.

Legal Proceedings:

We may disclose your medical information in the course of certain judicial or administrative proceedings.

Law Enforcement:

We may disclose your medical information for law enforcement purposes or to law enforcement officials under certain circumstances.

Coroners, Medical Examiners and Funeral Directors:

We may disclose your medical information to a coroner, medical examiner or a funeral director.

Organ Donation:

We may disclose your medical information to an organ procurement organization.

Research:

We may use or disclose your medical information for certain research purposes if an Institutional Review Board or a privacy board has altered or waived individual authorization, the review is preparatory to research or the research is only on decedent’s information.

Public Safety:

We may use or disclose your medical information to prevent or lessen a serious threat to the health or safety of another person or to the public.

Specialized Governmental Functions:

We may disclose medical information of Armed Forces personnel to military authorities under certain circumstances. If medical information is required for lawful intelligence, counterintelligence or other national security activities, or for the provision of protective services to the President of the United States or a foreign head of state, we may disclose it to authorized federal officials.

Workers’ Compensation:

We may disclose your medical information as authorized by laws relating to workers’ compensation or similar programs.

Business Associates:

We may disclose your medical information to a business associate with whom we contract to provide services on our behalf. To protect your medical information, we require our business associates to appropriately safeguard the medical information of our patients.

AUTHORIZATIONS:

We must have your authorization for any use or disclosure of your PHI involving certain mental health records (including psychotherapy notes), marketing activities, or sale of your information. We will not use or disclose your medical information for any other purpose without your written authorization except as otherwise permitted or required by law. Once given, you may revoke your authorization in writing at any time except to the extent that Forrest General Hospital has taken an action in reliance on the use or disclosure as indicated in the authorization. To request a Revocation of Authorization form, you may contact: Forrest General Hospital, Health Information Management Department, P.O. Box 16389, Hattiesburg, MS, 39404 or 601-288-2900.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:

You have the following rights with respect to your medical information:

You may ask us to restrict certain uses and disclosures of your medical information. In most cases we are not required to agree to your request, but if we do, we will honor it. We are required to comply with requests to restrict uses and disclosures of your medical information to a health plan if the purpose for the disclosure is not related to treatment and the health care services to which the medical information applies have been paid out-of-pocket in full.

You have the right to receive communications from us in a confidential manner.

Generally, you may inspect and copy your medical information. This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your medical information.

You may ask us to amend your medical information. We may deny your request for certain specific reasons. If we deny your request, we will provide you with a written explanation for the denial and information regarding further rights you may have at that point. We require you to submit your request for amendment and the reason for the request in writing. If you would like to request an amendment to your health information, please contact: Forrest General Hospital, Health Information Management Department, P.O. Box 16389, Hattiesburg, MS, 39401 or 601-288-2900.

You have the right to receive an accounting of the disclosures of your medical information made by Forrest General Hospital during the last six years (or following April 14, 2003), except for disclosures for treatment, payment or healthcare operations, disclosures which you authorized and certain other specific disclosure types. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You may request a paper copy of this Notice of Privacy Practices.

You have the right to receive notice from us in the event of any breach of your unsecured information. You have the right to complain to us and/or to the Secretary of the United States Department of Health and Human Services if you believe that we have violated your privacy rights. If you choose to file a complaint, you will not be retaliated against in any way. If you believe your privacy rights have been violated or if you would like further information regarding your rights or regarding the uses and disclosures of your medical information, please contact: Forrest General Hospital, Privacy Officer, P.O. Box 16389, Hattiesburg, MS, 39404 or 601-288-2810.

THIS NOTICE IS EFFECTIVE AS OF JULY 1, 2001.

REVISION OF NOTICE OF PRIVACY PRACTICES:

We reserve the right to change the terms of this notice, making any revision applicable to all the protected health information we maintain. If we revise the terms of this notice, we will post a revised notice at Forrest General Hospital and will make paper copies of the revised Notice of Privacy Practices available upon request.

FGH-830121
Approved: 07/01/01
Revised: 09/26/13