Polygon PT’S NOTICE OF PRIVACY PRACTICES
Effective April 22, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices apply to Polygon PT and each of its subsidiaries, affiliates, and entities managed or controlled by Polygon PT, including the corporate office and its employees. All of the entities will share personal health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law. Use or disclosure pursuant to this Notice may include electronic transmittal or disclosure of your personal health information.
We are required by law to maintain the privacy of our patients’ personal health information and to provide patients with notice of our legal duties and privacy practices with respect to personal health information. We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make a new Notice effective for all personal health information maintained by Polygon PT. Should we make a change, you may obtain a revised copy from the location providing treatment. We are also required to inform you that there may be a provision of State law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act. A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by mailing a request to the Privacy Officer, Polygon PT, 15591 Creekbend Dr #201, Sugar Land, TX 77478.
Uses and Disclosures for Treatment: We may make uses and disclosures of your personal health information as necessary for your treatment. Doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history etc.
Uses and Disclosures for Payment: We may make uses and disclosures of your personal health information as necessary for payment purposes. During the normal course of business operations, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. We may use your information to prepare a bill to send to you or to the person responsible for your payment.
Uses and Disclosures for Health Care Operations: We may use and disclose your personal health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your personal health information for purposes of improving the clinical treatment and patient care.
Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, outcomes data collection, legal services, etc. At times it may be necessary for us to provide your personal health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.
Appointments and Services: We may contact you to provide appointment reminders or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request, and we will accommodate reasonable requests by you, to receive communications regarding your personal health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You also have the right to request that we not send you any future marketing materials and we will use our best efforts to honor such request. You may make your requests by sending your name and address to Privacy Officer, P.O. Box 2034, Mechanicsburg, PA 17055.
Research: In limited circumstances, we may use and disclose your personal health information for research purposes. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board which oversees the research or by representations of the researchers that limit their use and disclosure of patient information.
Other Uses and Disclosures: We are permitted and/or required by law to make certain other uses and disclosures of your personal health information without your consent or authorization for the following:
- any purpose required by law;
- public health activities, such as required reporting of disease, injury, birth and death, or required public health investigations;
- if we suspect child abuse or neglect;
- if we believe you to be a victim of abuse, neglect, or domestic violence;
- to the Food and Drug Administration to report adverse events, product defects, or to participate in product recalls;
- to your employer when we have provided health care to you at the request of your employer;
- to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;
- in response to a court or administrative ordered subpoena or discovery request;
- to law enforcement officials as required by law to report wounds and injuries and crimes;
- to coroners and/or funeral directors consistent with law;
- if necessary to arrange an organ or tissue donation from you or a transplant for you;
- if you are a member of the military we may also release your personal health information for national security or intelligence activities;
- and to workers’ compensation agencies for workers’ compensation benefit determination.
You have the right to a copy and/or inspect much of the personal health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your legal representative. You may obtain a “Patient Access to Health Information Form” from the front office person. If you request a copy of your personal health information you may be charged a nominal fee for copying and postage.
You have the right to request in writing that personal health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests must be in writing, signed by you or your legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, we may notify others who work with us if we believe that such notification is necessary. You may obtain an “Amendment Request Form” from the front office person or individual responsible for medical records.
For patients whose medical treatment is covered under a state workers’ compensation program, please note the following: Disclosure of your protected health information (PHI) for purposes of providing treatment and obtaining payment under the state’s workers’ compensation is governed by the state workers’ compensation regulations and procedures. Therefore, we are not obligated to secure a written authorization as otherwise required by HIPAA in order to disclose your PHI for workers’ compensation purposes, nor may you restrict our use or disclosure of your PHI for workers’ compensation purposes. Written consent to use or disclose your PHI may be required pursuant to our internal policies and/or state workers’ compensation program rules in order to process your claims. Failure to provide any required written consent may result in your financial liability for medical services and supplies.
You have the right to receive an accounting of certain disclosures made by us of your personal health information after April 14, 2003. Requests must be made in writing and signed by you or your legal representative. “Accounting Request Forms” are available from the front office person or individual responsible for medical records. The first accounting in any 12-month period is free. You will be charged a fee for each subsequent accounting you request within the same 12-month period. You will be notified of the fee at the time of your request.
You have the right to request that we communicate with you in a certain way or at a certain location. Your request must be in writing and specify how and where you would like to be contacted. We will accommodate all reasonable requests.
You have the right to obtain a paper copy of this notice from us.
You have the right to be notified if you are affected by a breach of unsecured personal health information.
If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer, Polygon PT, 15591 Creekbend Dr #201, Sugar Land, TX 77478. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.
You have the right to request restrictions on uses and disclosures of your personal health information for treatment, payment, or health care operations. We are not required to agree to your restriction request, but will attempt to accommodate reasonable requests when appropriate. However, we must agree not to disclose your personal health information to your health plan if the disclosure is for payment or health care operations and relates to a health care item or service which you paid for in full out of pocket. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction by sending such termination notice to the individual responsible for medical records.
FOR FURTHER INFORMATION: If you have questions or need further assistance regarding this Notice, you may contact the Privacy Officer, Polygon PT, 15591 Creekbend Dr #201, Sugar Land, TX 77478, Telephone (832) 532-0144.