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HIPAA
Information
Notice of Privacy for Protected Health Information (PHI) under HIPAA
This
notice describes how Medical information about you may be used and disclosed
and disclosed and how you can get access to this information. The Federal
Government passed a new law in August 2002 dealing with the privacy of
patient records. The new law is called Health Insurance Portability and
Accountability Act. HIPAA for short. This is our general consent form.
Review it carefully.
Uses and Disclosures
Here are some examples of how we might have to use or disclose your health
care information. Your doctor or staff member at Keith Jay Wahl, M.D.,
Inc. may have to disclose your health information, including all of your
clinical records, to another health care provider or a hospital when it
is necessary to refer you to them for diagnosis, assessment, or treatment
protocol of your health condition.
Our insurance and billing staff may have to disclose your examination
and treatment records and your billing records to another party such as
an insurance carrier, HMO, PPO or your employer if they are potentially
responsible for the payment of your services.
Your doctor or staff member may need to use your health information, examination/treatment
records and your billing records for quality control purposes or for other
administrative purposes to efficiently and effectively run our practice.
Your doctor or staff member may need your name, address, phone number,
fax number or cell number as well as your clinical records to contact
you and provide appointment reminders, information about treatment alternatives
or chances, or other health related information that may be of interest
to you.
If you are not at home to receive an appointment reminder, a message will
be left on your answering machine or cell voice mail.
You have the right to refuse to give us authorization to contact you to
provide appointment reminders, information about treatment alternatives,
or other health related information. If you do not give us authorization,
it will not affect the treatment we provide to you or the methods we use
to obtain reimbursement for your care.
You may inspect or copy the information that we use to contact you to
provide appointment reminders, information about treatment alternatives,
changes in treatment protocols or other health related information at
any time.
Our Privacy Pledge
We have and always will respect your PRIVACY. Other than the uses and
disclosures we described above, we will not sell or provide any of your
health information to any outside marketing organization.
Permitted uses and disclosures without your consent or authorization:
Under FEDERAL law, we are also permitted or required to use or disclose
your health information without your consent or authorization in these
following circumstances:
* We are permitted to use or disclose your health information if we are
providing health care services to you based on the orders of another health
care provider.
* We are permitted to use or disclose your health information if we provide
health services to you as an inmate.
* We are permitted to use or disclose your health information if we provide
health care services to you in an emergency.
* We are permitted to use or disclose your health information if we are
required by law to treat you and we are unable to obtain your consent
after attempting to do so.
* We are permitted to use or disclose your health information if there
are substantial barriers to communicating with you, but in our professional
judgment we believe that you intend for us to provide care.
Other than the circumstance described in the preceding five examples,
any other use or disclosure of your health information will only be made
with your written authorization.
You’re right to revoke your authorization:
You may revoke your authorization to use at any time; however, your revocation
must be in writing
There are two circumstances under which we will not be able to honor your
revocation request.
* If we have already released your health information before we receive
your request to revoke your authorization.
* If you were required to give your authorization as a condition of obtaining
insurance, the insurance comp-any may have a right to your health information
if they decide to contest any of your claims.If you wish to revoke your
authorization, please write to us at:
Keith Jay Wahl, M.D., Inc
9834 Genesee Avenue Suite #425
La Jolla, CA 92037
Your right to limit uses or disclosures
If there are health care providers, hospitals, employers or other individuals
or organizations to whom you do not want us to disclose your information,
please let us know, IN WRITING, what invidivuduals or organizations to
whom you do NOT want us to disclose your health care information. We are
not required to agree to your restrictions. However, if we agree with
your restrictions, the restriction is binding on us. If we do not agree
to your restrictions, you may drop your request or you are free to seek
care from another health care provider.
Your right to receive confidential communication regarding your health
information
We normally provide information about your health to you in person at
the time you receive medical services from us. We may also mail you information
regarding your health or about this status of your account. We will do
our best to accommodate any reasonable request if you would like to receive
information about your health or the services that we provide, at a place
other than your home or, if you would like the information in a different
form. To help us respond to your needs, please make your request IN WRITING.
Your right to inspect and copy your health information
You have the right to inspect and/or copy your health information for
seven years from the date that the record was created as long as the information
remains in our files. We require your request to amend your records to
be IN WRITING and for you to give us a reason to support the change you
are requesting us to make. A reasonable fee for copying/postage will be
charged.
You’re right to receive an accounting of the disclosures we have
made of your records
You have the right to request that we give you so accounting of the disclosures
we have made of your health information of the last six years before the
date of your request. The accounting will include all of your disclosures
except:* Those disclosures required for your treatment, to obtain payment
for your services, or to run our practice
* Those disclosures made to you
* Those disclosures necessary to maintain a directory of the individuals
in our facility or to individuals involved with your care
* Those disclosures for national security or government intelligence purposes
* Those disclosures made to correctional officers or law enforcement agents
* Those disclosures that were made prior to the effective date of the
HIPAA privacy law
We will provide the first accounting within any 12-month period without
charge. There is a fee for any additional requests during the next 12-month
period. When you make your request we will tell you the amount of the
fee and you will have the opportunity to withdraw or modify your request
Our duties
We are required by law to maintain the privacy of your health information.
We are also required to provide with this notice of our legal duties and
our privacy practices with respect to your health information. We must
abide by the terms of this notice while it is in effect. However, we reserve
the right to change the terms of our privacy notices. If we make a change
to the terms of our privacy agreement, we will notify you IN WRITING when
you come in for your next treatment encounter or by U.S. Mail. If we make
a change in our privacy terms the change will apply for all of your health
information in our files.
Re-Disclosure
Information that we use or disclose may be subject to re-disclosure by
the person to whom we pride the information and may no longer be protected
by the Federal privacy rules.
Complaints
Complaints about this Notice of Privacy Practices or how we handle your
health information should be directed to Dr. Keith Wahl’s office.
If you are not satisfied with the manner in which we handle a complaint,
you may submit a formal complaint to:
Department of Health and Human Services
Office
of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
HIPAA/NOTICE
OF PRIVACY
THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT OYU MAY BE USED AND DISCLOSED
AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our Pledge
Regarding Your Health Information
We understand that information about you and your health is confidential.
We are committed to protecting the privacy of this information. Each time
you visit our office we create a record of the care and services you receive.
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 our office entities whether made by health care
personnel or your physician.
Our Responsibilities
Our primary responsibility is to safeguard your personal health information.
We must give you this notice of our privacy practices, and follow the
terms of the notice currently in effect.
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 have about you as well as any information
we receive in the future. We will post a copy of the current notice in
our office, and also on our web site. A copy of the notice currently in
effect will be available at the registration area of each facility.
How We May Use and Disclose Health Information About You
The following categories describe different ways that we use your health
information within our office and disclose your health information o persons
and entities outside of our office. We have not listed every use or disclosure
within the categories below, but al permitted uses and disclosures will
fall within one of the following categories. In addition, there are some
uses and disclosures that will require your specific authorization.
Treatment: We will use and disclose your protected health information
to provide, coordinate or manage your health care and any related services.
We may disclose health information about you to doctors, nurses, technicians,
medical students, interns or other allied health personnel who are involved
in taking care of your medical or pastoral needs during your visit with
us. We may communicate information to another health care provider for
the purposes of coordinating your continuing care. If you call, (858)
558-8868 to seek information for health care, we may use and disclose
the information you provide to us to a care team member to assist in providing
quality health care.
Payment: We may use and disclose your information to bill for services
provided by Dr. Wahl and to obtain payment from you, an insurance company,
a third party or a collection agency. This say include the disclosure
of health information to obtain prior authorization for treatment and
procedures from your insurance plan.
Appointment Reminders: We may use and disclose health information
to contact you as a reminder that you have an appointment for treatment
or medical care at our office.
Special Situations That Do Not Require Your Authorization
State or federal law permits the following disclosures of your health
information without verbal or written permission from you
Research: We may disclose your protected health information to
researches when permitted by law. For example, when preparing research
protocols when data is not removed.
Military and Veterans: If you are a member of the armed forces,
we may release health information about you as required by military command
authorities.
Worker’s Compensation: We may release health information about
you for worker’s compensation or similar programs if you have a work-related
injury. These programs provide benefits to you for your work-related injuries.
Averting 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 or safety or the health and safety of another person or
the public. These disclosures would be made only to someone able to help
prevent the threat.
Health Oversight Activities: We may disclose health information
to a health oversight agency for activities authorized by law. These oversight
activities include audits, investigations, inspections and licensure.
These activities are necessary for the government to monitor the health
care system, government programs and compliance with civil rights laws.
Public Health Activities: We may disclose health information about
you for public health activities. These generally include the following:
* To prevent or control disease, injury or disability
* To report births and deaths
* To report a child and adult abuse or neglect
* To report reactions to medications, problems with produces or other
adverse events
* To notify people of recalls of products they may be using
* 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
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 administrative
order. We may disclose health information about you in response to a subpoena,
discovery request or other lawful process by someone else involved in
the dispute.
Law Enforcement: We may disclose health information if asked to
do so by law enforcement official for the following reasons:
* In response to a court order, subpoena, warrant, summons or similar
process
* To identify or locate a suspect, fugitive, material witness or missing
person
* To identify the victim of a crime if, under certain circumstances, we
are unable to obtain the person’s authorization
* To release information about a death we believe may be the result of
criminal conduct
* Criminal conduct at our office
* Emergency circumstances, to report a crime, the location of the crime
or victims, or the identity, description or location of the person who
committed the crime.
Coroners, Medical Examiners and Mortuaries: We may disclose health
information to a coroner or medical examiner. This may be necessary to
identify a deceased person or determine the cause of death of a person.
We may release health information about patients at our facility to mortuaries
as necessary to carry out their duties.
National Security and Intelligence Activities: We may disclose health
information about you to authorized federal officials for intelligence,
counterintelligence and other national security activities authorized
by law.
Inmates: if you are an inmate of a correctional institution or
under custody of a law enforcement official, we may disclose health information
about you to the correctional institution or the law enforcement official.
This is necessary for the correctional institution to provide you with
health care, to protect your health and safety and the health and safety
of others or for the safety and security of the correctional institution.
Legal Requirements: We will disclose health information about you
without your permission when required to do so by federal, state or local
law.
Situations Requiring Your Verbal Agreement
Individuals Involved In Your Care Or Payment For Your Care: We
may disclose health information about you to a family member or friend
who is involved in your medical care, unless you tell us in advance not
to do so. In addition, we may disclose health informational about you
to any entity assisting in a disaster relief effort (such as the Red Cross)
so that your family can be notified about your conditions, status and
locations
Situations Requiring Your Written Authorization
If there are reasons we need to use your information that have not been
described in the sections above, we will obtain your written permission.
This permission I described as an "authorization." If you authorize
us to use or disclose health information about you, you may revoke that
authorization in writing at any time. If you revoke your authorization,
we will no longer use or disclose health information about you for the
reasons stated in your written authorization. Please understand that we
are unable to take back any disclosures we have already made with your
permission, and we are required to retain our records of the care we provide
you. Listed below are some typical disclosures that require your authorization.
Research:
When a research study involves your treatment, or in certain circumstance
records research, we may disclose your health information to researches
only after you have signed a specific written authorization. In addition,
an Institutional Review Board (IRB) will already have reviewed the research
proposal, established appropriate protocols to ensure the privacy of your
health information and approved the research. You do not have to sign
the authorization, but if you refuse you cannot be part of the research
study and may be denied research-related treatment.
Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain
about you. You may contact a health information representative where services
were provided to entail additional information and instructions for exercising
the following rights.
Obtain a copy of you Notice of Privacy Practices
Request a restriction on certain uses and disclosures of your information.
This request must be in writing. If we agree to your request, we will
comply unless the information is needed to provide you with emergency
treatment. However if our system capabilities will not allow us to comply
with your request, we are not required too. We can only address requests
for our office and other affiliated facilities. Tour request will not
extend to a physicians’ private practice.
Inspect and request a copy of your health record. Your request for inspection
or copies must be in writing and directed to Keith Jay Wahl, M.D. A reasonable
fee for copies will be charged. We request that the denial be reviewed
by another health care professional chosen by someone on our health care
staff.
Request an amendment to your health record if you feel the information
is incorrect or incomplete. Your request must be made in writing and it
must include a reason that supports the request. We may deny your request
if the information was not created by our health care team, if it is not
part of the information kept by our facility, it is not part of the information
which you are permitted to inspect and copy, or if the information is
accurate and complete as stated. Please note, if we accept your request
for amendment, we are not required to delete any information from our
heath record.
Obtain an accounting of disclosures to others of your health information.
The accounting will provide information bout disclosures made for you
purposes other than treatment, payment, health care operations, disclosures
excluded by law or those you have authorized.
Request confidential communications. You have the right to request
that we communicate with you about medical matters in a certain way or
at a certain location. For example, you may ask that we only contact you
at work or by mail. We will accommodate all requests that are reasonable
for our system capabilities. Your request must be in writing and specify
the exact changes you are requesting.
Revoke your authorization. You have the right to revoke your authorization
for the use or disclosure of your health information except to the extent
that action has already been taken.
Right to a copy of this Notice of Privacy Practices. You have a
right to a paper copy of this Notice of Privacy Practices.
Changes
to this Notice of Privacy Practices. We reserve the right to amend
this Notice of Privacy Practices at any time in the future. Until such
amendment is made, we are required by law to comply with this Notice.
After an amendment is made, the revised Notice of Privacy Protections
will apply to all protected health information that we maintain, regardless
of when it was created or received. We will keep a copy of the current
notice posted in our office.
Complaints:
Complaints about this Notice of Privacy Practices or how we handle your
health information should be directed to Dr. Keith Wahl’s office.
If you are not satisfied with the manner in which we handle a complaint,
you may submit a formal complaint to:
Department of Health and Human Services
Office
of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
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