Westfield Family Physicians, P.C. and Great Lakes Medical Research, L.L.C.
(Effective April 14, 2003)
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.
Westfield Family Physicians, P.C. and Great Lakes Medical Research, L.L.C. together are an organized healthcare arrangement, and the providers use health information for treatment, billing, healthcare operations, and for other uses permitted by law. This Notice applies to Westfield Family Physicians, P.C. and Great Lakes Medical Research, L.L.C. with offices at 138 East Main Street, Westfield, NY 14787 and 115 East Main Street, Sherman, NY 14781.
Each time you visit one of our offices, a record of your visit is made. This record typically contains information about your symptoms, examination, test results, diagnoses, treatment, and a plan for future care. This protected health information (or PHI) serves as a:
• basis for planning your care and treatment
• means of communication among the other health care providers who may contribute to your care;
• legal document describing the care you received;
• means by which you or a third party payer can verify that services billed were actually provided;
• source of data for purposes of billing for medical services provided;
• tool in educating health professionals;
• source of data for medical research;
• source of information for public health officials charged with improving the health of the nation;
• source of data for facility planning and marketing; and
• a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Westfield Family Physicians and Great Lakes Medical Research are required to
• maintain the privacy of your PHI;
• provide you with a notice as to our legal duties and privacy practices with respect to PHI we collect and maintain about you;
• and abide by the terms of this Notice.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. In the event that there is a material change to our privacy practices, we will post a revised Notice in a prominent location in our offices, provide you with a copy of the revised Notice upon your request, and make the revised Notice available on our websites, www.wfpweb.net and www.glmr.info.
Except as described in this Notice, we will not use or disclose your PHI without your written authorization. Furthermore, you have the right to revoke such authorization.
• Example 1. Your PHI will be used for treatment: You arrived for an appointment to see the doctor for treatment of an ear infection. The nurse and physician both asked you questions about your condition and recorded their findings in your medical record. The physician recorded a note in your record that includes the symptoms, a diagnosis, and a plan for treatment of your infection.
• Example 2. Your PHI will be used for payment: Following your visit to the doctor, an employee in our billing office created a claim (paper or electronic form) that was submitted to your insurance company or HMO for payment for the services provided to you. The information on the claim may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
• Example 3. Your PHI will be used for health care operations: Members of a quality improvement team may use information in your health record to assess the quality of the care given. This information will be used in an effort to improve the quality of the services provided.
Following are some uses and disclosures of PHI that are either permitted or required by law:
• We may disclose your PHI to other individuals who are authorized by law to act on your behalf with respect to your PHI. We will only disclose to such personal representatives PHI that is permitted by state and/or federal laws.
• We contract with some business associates to whom we disclose your PHI. For example, notes from your visit may be dictated on to a cassette tape (or other media storage device) and then sent to an individual for transcription. We require the business associate to appropriately safeguard your PHI.
• Unless you notify us that you object we may use your name, location in the facility, general condition and religious affiliation for the purpose of keeping a directory of individuals within our facilities.
• Unless you notify us that you object, we may use our best judgment to disclose PHI to a family member, other relative, close personal friend or other person you identify if that PHI is relevant to that person’s involvement in your care or payment related to your care. In certain circumstances, we may also use your PHI to notify such persons of your location, general condition, or death.
• We may contact you to provide appointment reminders, the results of a test ordered by one of our providers or staff, treatment alternatives, and other PHI related to your care, and benefits and services that may be of interest to you.
• We may use your PHI to determine your potential eligibility for participation in research studies conducted by researchers in our offices. For these research preparation activities, we will not remove your PHI from our facility.
• We may use or disclose your PHI for research purposes under certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes, except in situations where a research project meets specific, detailed criteria established by federal law for privacy protection.
• We may use or disclose a limited data set of PHI that has had some identifying information removed for the purposes of research, public health, or health care operations. The person who receives the information must sign an agreement to protect the information.
• We may disclose PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
• We may disclose to the Food and Drug Administration (FDA) PHI relative to adverse events with respect to food, supplements, product and product defects or post marketing surveillance information to enable product recalls, repairs or replacement.
• We may disclose PHI to coroners, medical examiners and funeral directors, consistent with applicable law, to carry out their duties.
• Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
• We may disclose your PHI to individuals authorized by law to assist in disaster relief efforts.
• We may disclose your PHI to authorized persons to report disease, injury, birth, or death.
• As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury or disability.
• We may disclose your PHI to notify a person who may have been exposed to a communicable disease in order to control the spread of disease.
• In certain limited circumstances, we may disclose your PHI to a person who is able to prevent a serious threat to the health or safety of a person or to the public.
• We may disclose your PHI to public health authorities or other authorized persons to report child abuse or neglect, other neglect or abuse, and domestic violence.
• Under limited circumstances, we may disclose to your employer PHI that is related to workplace injuries or illnesses, or workplace surveillance.
• Should you be an inmate of a correctional institution, we may disclose to the institution, or agents thereof, PHI necessary for your health, and the health and safety of other individuals.
• We may disclose your PHI for law enforcement purposes as required by law, or in response to a valid subpoena.
• We may disclose your PHI to an appropriate health oversight agency or public health authority for various activities to monitor the health care system, government health care programs, and compliance with certain laws.
• We may disclose your PHI to certain government authorities and other authorized individuals for certain specialized government functions as required by law.
• We are required to disclose PHI to the Secretary of the U.S. Department of Health and Human Services, when requested by the Secretary, to review our compliance with federal privacy laws.
• We may disclose PHI that is used or disclosed incident to a permitted disclosure under the HIPAA Privacy Rule as long as we have reasonably safeguarded against such incidental disclosures and have limited them to the minimum information necessary for the purpose of the disclosure.
Although your health record is the physical property of the healthcare provider or facility that compiled it, the information belongs to you.
You have the following rights with respect to your PHI.
• You may obtain a paper copy of the Notice of Privacy Practices upon request.
• You may have the right to inspect and obtain a copy of your PHI in certain circumstances as provided by 45 CFR 164.524. If we make a copy of your PHI for you to take with you, please understand that once it is given to you, we are no longer responsible for what happens to that PHI in your possession. We may charge a fee for copying and giving you a copy of your records.
• If you decide to voluntarily participate in a research study, you may be asked to sign a consent form agreeing to suspend your right to access some of your health information until the completion of the research trial.
• You may have the right to amend your PHI in certain circumstances as provided by 45 CFR 164.526. All requests for an amendment should be in writing addressed to our Privacy Officer, and should include an explanation of the reasons for the request.
• You have the right to request a restriction on certain uses and disclosures of your PHI as provided by 45 CFR 164.522. We are not required to agree to your request.
• You may have the right to obtain an accounting of disclosures of your PHI in certain circumstances as provided by 45 CFR 164.528. All requests for such an accounting should be in writing addressed to our Privacy Officer.
• You have the right to request communications of your PHI by alternative means or at alternative locations. We are required to accommodate only reasonable requests. All such requests for alternative communications should be in writing addressed to our Privacy Officer.
If you believe your privacy rights have been violated, you can file a complaint with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
If have questions, complaints, or would like additional information, you may call (716) 326-4678 and ask for our Privacy Officer. You may also write to our Privacy Officer at:
Westfield Family Physicians, P.C.
Attn: Privacy Officer
P.O. Box 10
Westfield, NY 14787
Recognizing that today’s research is vital to the growth and development of tomorrow’s healthcare practices, we at Great Lakes Medical Research are dedicated to conducting clinical research with compassion, expertise, and respect for each participant as a valued individual.
phone (716) 326-4890
toll free 1 (877) 326-4567