Summary of Privacy Practices
We at the Allergy, Asthma and Sinus Center take our responsibility for protecting your medical information very seriously. We have prepared this privacy practice summary and all
of our policies in accordance with federal and state law in an effort to help you understand (1) how we will handle your medical information, (2) when we will and won’t release it, (3) how to let us know if you have questions or concerns, and (4) your rights related to this health information.
In an effort to help you better understand this process, the following definitions are provided:
Protected Health Information (PHI):
Any health information that can be used to identify you, which we maintain or transmit in written, oral, or electronic form. It may relate to your past, present, or future medical health or services.
Whenever we release PHI, we will release only that which is necessary to accomplish the purpose for which it is requested. In addition, our employees will only access your records to the degree needed to perform their particular job.
Releasing Your PHI Without Your Specific Approval
We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. We will also disclose your health information to other physicians or facilities who may be treating you or to whom we refer you. For example, we will give information to your primary care physician or a hospital where you will receive services.
We will use and disclose your PHI to obtain payment for the health care services we provide you. For example, we will send your insurance company a bill that details the procedure(s) that we performed, your diagnosis, and other identifying information.
Health Care Organizations:
We will use and disclose your PHI to support the business activities of our practice. For example, we may disclose your information to third party business associates who perform billing, collections, consulting, or transcription services. However, we will have a contract in place with each of these associates that ensures that they will maintain the privacy of your information.
Other Authorized User/Disclosures:
The law allows a number of specific other uses or disclosures that do not require your authorization. These include uses for (1) public health and safety activities, (2) evidence of abuse or domestic violence, (3) judicial or administrative proceedings, (4) law enforcement, (5) research, (6) Worker’s Compensation claims, and (7) specialized government functions. For more detailed information on these uses, you can review our complete “Notice of Privacy Practices,” which is available upon request.
Your Health Information Rights
Although the health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. You have the right to:
A complete copy of this “Summary of Privacy Practices” and/or a complete copy of the “Notice of Privacy Practices.” You may obtain a copy by asking our receptionist during you visit or by calling and asking that a copy be mailed to you.
Inspect and Copy: You have the right to inspect and copy the PHI that we maintain about you in our designated set for as long as we maintain information. This includes your medical and billing records that we created or that were created at our request (e.g. x-rays, CT scans, labwork, etc.). We will not release to you any records that are originated from another provider facility. Those records will need to be obtained directly from that office or facility.
If you wish to inspect or copy your medical information, you must submit your request in writing to our Privacy Officer at the address on the bottom of this form. We have thirty days to respond to your request for information. If your records are stored off-site, we have up to sixty days to respond to your request, but we will notify you of the delay.
Amend Your Records:You have the right to request that we amend your PHI if you feel it is incomplete or inaccurate. You must make this request in writing to our Privacy Officer, stating exactly what you feel is incomplete or inaccurate and the reasoning that supports your request.
We are permitted to deny your request if it is not in writing or does not include a reason to support the request. We may also deny the request if:
- The information was not created by us, or the person who created it is no longer available to make the amendment,
- The information is not part of the record which you are permitted to inspect or copy;
- The information is not part of the designated record set kept by this practice, or
- It is the opinion of the health care provider that the information is accurate and complete.
Request Restrictions: You have the right to request a restriction or limitation of how we use or disclose your medical information for treatment, payment, or health care operations. For example, you could request that we not disclose information about a prior treatment to a family member or friend who may be involved in your care or payment for care. Your request must be in writing.
Request Confidential Communications: You have the right to request how we communicate with you to preserve your privacy. For example, you may request that we call you only at a specific phone number or by mail at a specific address. Your request must be in writing and must specify how and where we are to contact you. We will accommodate all reasonable requests.
File a Complaint: If you believe we have violated your medical information privacy rights, you have the right to file a complaint with our privacy officer or directly to the Secretary of Health and Human Services.
To file a complaint with our Privacy Officer, the complaint must be within 180 days of the suspected violation. Provide as much information as you can and send it to the address below.
Uses or Disclosures Not Covered
We will release your PHI under other circumstances only with your written permission. There is no charge for the release of information that is part of Treatment, Payment of Health Care Operations. When records are released directly to another provider, there is no charge.
Allergy, Asthma, and Sinus Center, P.C.
1200 Valley West Dr. Suite. 120
West Des Moines, IA 50266
phone: (515) 226-9559
fax: (515) 226-1673