Patient Services, Inc.
Notice of Privacy Practices
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.
Effective September 26, 2014
If you have any questions about this notice, please contact our Privacy Officer at 1-800-366-7741. Written requests may be made via email to email@example.com or to the address below:
Patient Services, Inc.
Attn: Privacy Officer
P.O. Box 5930
Midlothian, Virginia 23112
Our Commitment To Your Privacy
We understand the importance of keeping your personal and health information secure and private. By following the Health Insurance Portability and Accountability Act of 1996 ('HIPAA'), we maintain the privacy of your protected health information ('PHI'; in written, verbal, and electronic form), provide you with notice of our legal duties and privacy practices with respect to your PHI, and abide by the terms of this notice.
This notice informs you of your rights about the privacy of your PHI and how we may use and share your PHI. We ensure that your personal information is only used and shared in the manner described. If this notice is updated, changes will apply to PHI that we already have about you as well as any PHI that we may receive or create in the future. You may request a copy of our privacy practices at any time.
When it comes to your PHI, you have certain rights.
This section explains your rights and some of our responsibilities to help you. You have the right to:
- Get a copy of your PSI Patient File
- Correct your PSI Patient File
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we’ve shared your PHI
- Get a copy of this privacy notice
- Choose someone to act for you and/or have your PHI disclosed to them
- Request restrictions
- File a complaint if you believe your privacy rights have been violated.
Get a copy of your PSI Patient File
You can inspect and obtain a copy of your PSI Patient File. We will provide a copy or a summary of your PSI Patient File, usually within 15 days of your request. To inspect and copy your PHI, you must submit your request in writing to our Privacy Officer at the address listed on the first page of this notice. As allowed by local law, we may charge a fee for the costs of copying, mailing, labor, and supplies related to your request. You may also request your PSI patient file in electronic form if we maintain it in an electronic form.
Ask us to correct your PSI Patient File
You may ask us to amend your PSI Patient File if you believe it is incorrect or incomplete. To request an amendment, you must submit your request in writing to our Privacy Officer at the address listed on the first page of this notice. You must provide us with a reason that supports your request. We may deny your request if the information is accurate, but you reserve the right to submit a statement of disagreement. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
You can request that we communicate with you about your health and related issues in a certain way, or at a certain location. For example, you may ask that we contact you by mail, rather than telephone, or at work, rather than at home. To request confidential communications, you must make your request in writing to our Privacy Officer at the address listed on the first page of this notice. We will accommodate reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.
Ask us to limit what we use or share
You have the right to request restrictions on certain uses and disclosures of your PHI. However, PSI is not required to agree to any such requested restriction. To request a restriction on the use and disclosure of your PHI, you must make your request in writing to our Privacy Officer at the address listed on the first page of this notice. In your request, you must tell us what information you want to limit and to whom you want the limitations to apply. We may say “no” to your request, but we’ll tell you why in writing.
Get a list of those with whom we’ve shared your PHI
You can ask for a list (accounting) of the times we’ve shared your PHI for six years prior to the date you ask, who we shared it with, and why. To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer at the address listed on the first page of this notice. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you and/or have your PHI disclosed to them
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices. We will make sure the person has this authority and can act for you before we take any action. You may also give verbal or written authorization to have your PHI disclosed to another individual such as a family member.
File a complaint if you feel your rights are violated
You can file a complaint if you feel we have violated your rights by contacting the Privacy Officer through the information listed on the first page of this notice. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
How do we typically use or share your PHI?
We typically use or share your PHI in the following ways.
Help manage the health care treatment you receive
We can use your PHI and share it with professionals who are treating you. Example: A doctor sends us PHI about your diagnosis and treatment plan so we can arrange additional services.
Run our organization
We can use and disclose your PHI to run our organization and contact you when necessary. Example: We use PHI about you to develop better services for you.
Pay for your health services
We can use and disclose your PHI as we pay for your health services. Example: We share PHI about you with your health insurance company or a pharmacy.
Administer the program under which you are receiving assistance
We may disclose your PHI to your health plan sponsor for program assistance administration. Example: We contract with a Pharmacy Benefit Manager (PBM) to process and pay prescription drug claims, and we provide certain PHI so that we can process and pay the claim for you.
How else can we use or share your PHI?
We are allowed or required to share your PHI in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your PHI for these purposes. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share PHI about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety.
We can use or share your PHI for health research.
Comply with the law
We will share PHI about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to lawsuits and legal actions
We can share PHI about you in response to a court or administrative order, or in response to a subpoena.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director
We can share PHI about you with organ procurement organizations. We can share PHI with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share PHI about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services.
For certain PHI, you can tell us your choices about what we share.
If you have a clear preference for how we share your PHI in the situations described below, please tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:
- Share PHI with your family, close friends, or others involved in payment for your care
- Share PHI in a disaster relief situation.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your PHI if we believe it is in your best interest. We may also share your PHI when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your PHI unless you give us written permission
- Marketing purposes
- Sale of your PHI
- We are required by law to maintain the privacy and security of your PHI.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your PHI.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your PHI other than as described here unless you tell us we can in writing or through electronic consent. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all PHI we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.