If you have any questions about this Notice please contact our Privacy Official, Diane Rabideau, RN, IV-C.
At Chase Medical Research, (“CMR”), we are committed to protecting and preserving your privacy. We understand that health information about you is personal and that you are concerned over how it is used. This Notice of Privacy Practices describes:
This notice applies to the information and records we have about your health, health status, and the health care and clinical trial services you receive at this office. “Protected health information” is information about you that relates to your past, present, or future physical or mental health or condition and related health care services, and that includes demographic information that may identify you. This Notice will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information. The terms of this Notice apply to all records containing your protected health information that are created or retained by our office.
We are required by federal law to maintain the privacy of your protected health information, as describes! in this notice. We are also required to provide you with and abide by the terms of this Notice of Privacy Practices. We may change the terms of this Notice of Privacy Practices at any time, and the new Notice of Privacy Practices will be effective for all protected health information that we maintain at that time. We will provide you with any revised Notice of Privacy Practices upon your request by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. We will at all times keep a copy of the most current version of this Notice posted in a visible location in our offices.
1. HOW CMR USES AND DISCLOSES YOUR PROTECTED HEALTH INFORMATION
A. Uses and Disclosures of Protected Health Information for Research:
CMR must have your written, signed Authorization, and must have provided you with this Notice and given you a chance to acknowledge that you have received it, in order to use or disclose your protected health information in connection with your participation in clinical trials. In this context, we may use health information about you to provide you with medical treatment or services as part of our clinical trials. We may disclose health information about you to doctors, nurses, technicians, coordinators, office staff, or other personnel who are involved in conducting our clinical trials. We may also use and disclose your protected health information to organizations that sponsor our research, organizations that monitor our research, and the FDA.
However, under limited circumstances we are not required to obtain your written authorization to use your protected health information for research purposes. When the Internal Review Board or Privacy Board has determined that a waiver of your authorization meets certain criteria to ensure the privacy of your protected health information, we will not be required to obtain your Authorization in order to use your protected health information for research purposes.
You may revoke your Authorization at any time by giving us written notice. Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures of protected health information that occurred before that time, If you do revoke your Authorization, we will not be permitted to use or disclose information for purposes of research, and we may therefore choose to discontinue your participation in our clinical trials and any related health care treatment and services.
B. Permitted Uses and Disclosures of Protected Health Information:
CMR must have provided you with this Notice and given you a chance to acknowledge that you have received it in order to use or disclose your protected health information as described in this Section 1(B). Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice. Following are examples of the types of uses and disclosures of your protected health care information that the physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.
Treatment: We may use health information about you to provide you with medical treatment or services, and to coordinate or manage your health care and any related services. We may disclose health information about you to doctors, nurses, technicians, office staff, or other personnel who are involved in taking care of you and your health. For example, to participate in a clinical trial our staff may need to know if you have other health problems that could complicate your participation or include/exclude you from participation. We may also disclose your protected health information to a third party in order to coordinate and manage your care. For example, the study doctor may also tell another physician or health care provider about your condition so that doctor can help determine the most appropriate care for you and make recommendations regarding your clinical trial participation. In addition, our staff may use your medical history to decide what clinical trial is best for you. In addition, different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy, scheduling lab work and ordering x-rays. Family members and other health care providers may be part of your medical care outside this office and may require information about you that we have.
Payment: We may use and disclose your protected health information as needed so that you may receive a stipend for your clinical trial participation.
Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of CMR. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, certain limited marketing activities, and conducting or arranging for other business activities. For example, we may use your protected health information to evaluate the performance of our staff in caring for you. We may also use protected health information about all or many of our participants to help us decide what additional clinical trials we should offer, how we can become more efficient, or whether certain new treatments are effective. We will share your protected health information with third party “business associates” that perform various activities (e.g., transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
Health-Related Benefits and Services; Treatment Options: We may use and disclose protected health information about you to inform you of other health-related services or benefits offered by our office or an affiliated organization that may be of interest to you, or to provide you with information about potential clinical trial alternatives or treatment options that may be of interest to you. We may also use and disclose your protected health information for other limited marketing activities; for example, your name and address may be used to send you a newsletter about our office and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Official to request that these materials not be sent to you.
Appointment Reminders: We may use and disclose your protected health information, as necessary, in contacting and reminding you of your upcoming appointment(s). You may contact our Privacy Official to request that you not be contacted for appointment reminders.
C. Other Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your physician or CMR has taken an action in reliance on the use or disclosure indicated in the authorization.
D. Other Permitted and Required Uses and Disclosures that May be Made With Your Authorization or Opportunity to Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Family, Friends and Others Involved in Your Health Care: We may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care, unless you tell us that you object to such disclosures. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to provide you with this Notice as soon as reasonably practicable after the delivery of treatment. If your physician or another physician within CMR is required by law to treat you and the physician has attempted to provide you with this Notice but is unable to do so, he or she may still use or disclose your protected health information to treat you.
E. Other Permitted and Required Uses and Disclosures that May Re Made Without Your Consent, Authorization, or Opportunity to Object
We may use or disclose your protected health information in the following situations without your authorization or opportunity to object. These situations include:
Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, or biologic product deviations; to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request, or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and instances otherwise required by law, (2) limited information requests for identification and location purposes, (3) requests pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) the event that a crime occurs on the premises of the practice, and (6) a medical emergency (not on the Practice’s premises) when it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his or her duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaver organ, eye, or tissue donation purposes.
Research: We may use and disclose your protected health information for research purposes in certain limited circumstances. We will obtain your written authorization to use your protected health information for research purposes, as noted above, except when the Internal Review Board or Privacy Board has determined that a waiver of your authorization meets certain criteria to ensure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation: Your protected hearth information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
2. YOUR RIGHTS
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and CMR use for making decisions about you.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Our office may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Please contact our Privacy Official if you have questions about access to your medical records.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of for clinical trial eligibility and participation, treatment, payment, or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. CMR is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If CMR does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment or it is required by law. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by putting your request in writing, including a detailed description of your requested restriction, and presenting it to our Privacy Official and to your physician.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Official.
You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Official to determine if you have questions about amending your medical record
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than clinical trial eligibility and/or participation, treatment, payment, or health care operations as described in this Notice of Privacy Practices. However, there are certain disclosures that we are not required to, and will not, include in such accounting, including disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions, and limitations.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Official of your complaint. We will not retaliate against you for filing a complaint. You may contact our Privacy Official, Diane Rabideau, RN, IV-C at (203) 419-4420, or via e-mail at email@example.com for further information about the complaint process.