To our patients:
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
Mid-South Imaging and Therapeutics, P.A.
Notice of Privacy Practices
(Full-length Notice – Patient Copy)
You should have received a short-form summary notice to sign along with this full-length version. If you did not, please request one from our staff person who provided this form to you. If you have any questions after reviewing this information, please direct them to the person who provided this notice to you, or to our Privacy Officer (whose contact information is contained in this notice).
UNDERSTANDING YOUR MEDICAL RECORD/HEALTH INFORMATION
Each time you visit a hospital, physician, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information is often referred to as your “medical record.” This information and other information relating to your care are referred to in this notice as “Health Information.” The doctors and staff of Mid-South Imaging & Therapeutics, P.A. (our “Practice”) maintain Health Information relating to the care you receive from us.
The Health Information contained in your record is useful for a number of reasons. For example, this information:
- Serves as a basis for planning your care and treatment
- Provides a means of communication among the many health professionals who contribute to your care
- Describes the care you received
- Allows you, your insurance company or other third-party payer to verify that services are accurately billed
- Allows health care professionals and organizations involved in your care to conduct treatment, payment, and operational activities
- Contains information we will need to contact you about appointment reminders, treatment alternatives, or other health-related benefits
Understanding what is in your record and how your Health Information is used helps you to ensure its accuracy and to better understand who, what, when, where, and why others may access your Health Information. This, in turn, allows you to make more informed decisions about its use and disclosure.
YOUR HEALTH INFORMATION RIGHTS
Although your Health Information at our offices is the physical property of our Practice, you have certain rights relating to this information. As a patient, you are generally entitled to:
- Obtain a copy or summary of your Health Information or to inspect such information (a reasonable fee may be charged)
- Request an amendment to your Health Information where you feel there is an error
- Request a restriction on certain uses and disclosures of your Health Information (we will consider reasonable, appropriate requests, but are not obligated to agree to them)
- Obtain an accounting of certain disclosures of your Health Information (a reasonable fee may be charged to fulfill repeated requests for accountings)
- Request that communication of your Health Information made to you be made by alternative means or at alternative locations (for example, a certain postal address or phone number). Please be aware that it is our standard practice to use any or all of the information you have provided to us in order to contact you for purposes of treatment (for example, conveying test results), payment, and business operations (for example, scheduling appointments, providing reminders). We may use mailings and may leave messages on your answering machine, voice mail, or with others who may answer your phone for these purposes. Also, if contact information we have for you is no longer valid, we may contact other persons identified in your record (for example, family members, persons identified as an emergency contact) to obtain updated contact information on you. If you wish to limit or specify the means by which we contact you, you may request our Patient Request Form and return it to the our Privacy Officer as provided below. You do not need to give a reason for your request. Our Practice will accommodate requests we determine to be reasonable
- Revoke a previous authorization to certain uses and disclosures of your Health Information by our Practice (that you may have provided under a written authorization), except where actions have already been taken relating to that authorization
To exercise any of these rights, you must submit a request in writing. Please contact our Privacy Officer to obtain written request forms or to ask any questions you have regarding these rights. You can contact our Privacy Officer, Worth Saunders, at (901) 747-1000. Communications may also be sent by mail to: Privacy Officer, Mid-South Imaging & Therapeutics, P.A., 6305 Humphreys Blvd., Suite 205, Memphis, TN 38120.
Our Practice is required by law to take measures designed to protect the privacy of your Health Information and to provide you with this notice describing our privacy practices and legal duties. We are also required to abide by the terms of our current notice. We reserve the right to change our notice and privacy practices, and to make the new provisions effective for all protected health information we maintain, including your Health Information. Should our privacy practices change, we will post our revised notice at our offices and at our website at http://www.msit.com/disclaimer.html. An updated version may also be obtained if you request a copy from our Privacy Officer or from staff during a visit to our offices.
We will not use or disclose your Health Information without obtaining your written authorization except as consistent with this notice or as otherwise required or permitted by law (for example, in emergency treatment situations).
Although other health care providers may provide treatment to you (for example, hospitals or other physician groups) and we may share your Health Information with them for treatment, payment, and certain operations purposes, we are not jointly managed with or owned by such providers. They are separate entities and will have their own policies and procedures for handling your Health Information.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If have questions and would like additional information, you may contact our Practice’s Privacy Officer, Worth Saunders, at (901) 747-1000. Communications may also be sent by mail to: Privacy Officer, Mid-South Imaging & Therapeutics, P.A., 6305 Humphreys Blvd., Suite 205, Memphis, TN 38120. If you believe your privacy rights have been violated, please file a complaint with the Privacy Officer, as listed above, or with the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint.
EXAMPLES OF POSSIBLE USES AND DISCLOSURES OF HEALTH INFORMATION
We will use your Health Information for treatment. For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine your course of treatment. Members of your health care team will then record the actions they took and their observations. Our Practice may also provide copies of your Health Information to other health care providers who take care of you.
We will use your Health Information for payment. For example: A bill may be sent to you or your insurance company or other third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. Our Practice may also provide other health care providers involved in your care with information to assist in their billing and payment activities.
We will use your Health Information for our business operations: For example: Our Practice doctors and staff may use information in your health record to assess the care and outcomes in your case and others like it or to train students or other health professionals. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and services we provide.
Vendors: There are some services provided in our organization through contracts with outside vendors. For example, we might use a copy service to make copies of patient records for us. When such services are contracted, we may disclose your Health Information to our vendors so that they can perform the job we’ve asked them to do. To help protect your Health Information, we require vendors to agree in writing to safeguard Health Information, consistent with the same standards that we are required to observe.
Organized Health Care Arrangements. In some settings, we may be part of a clinically integrated care setting in which you typically receive health care from more than one health care provider (for example, a hospital). Also, we may participate in arrangements with other health care entities to conduct joint health care-related activities. In these settings and arrangements, your Health Information may be shared between us and the other providers or participants for treatment, payment, and certain operations purposes. These other providers or participants remain separate entities from us and will have their own policies and procedures for handling your Health Information.
Notification: We may use or disclose your Health Information to notify or assist in notifying a family member, personal representative, or other person responsible for your care, of your location and general condition in the event you are unable to care for yourself.
Communication with family: Unless you object and inform us of your objection, we may disclose to your spouse, other family members/relatives, or close personal friends, or to any person you have identified as being involved in your care, Health Information that is in our judgment relevant to that person’s involvement in your care or payment for your care.
Note to persons under the age of 18: Good medical practice, payment requirements, or state law may make it necessary to tell your parent or guardian about your visit or provide them with all or part of your Health Information. If this is a concern to you, please discuss your concern with your doctor or our Practice’s Privacy Officer before you receive services.
Limited data sets and de-identified information: In many instances where we use or disclose information for purposes of research, public health, or health care operations, certain information (names, social security numbers, etc.) will be removed to help protect the identity of the patient.
Research: Our Practice and its practitioners may become involved as a study site and serve as researchers for certain research trials. In order to provide you with useful information concerning the availability of such trials, we may review your medical record from time to time to see whether you might be eligible to participate in certain studies in which you may then have access to experimental treatments. If it appears that you may be eligible for participation in a trial, your doctor or a member of our privacy workforce will contact you to ask whether you may be interested and to provide further information. Beyond these preparatory activities, we will only use or disclose your health information for research purposes in limited circumstances -- for example, where you have signed a specific written authorization, where a research protocol has been designed and approved by a research IRB, or where other precautions have been used consistent with federal privacy regulations.
Deaths: We may disclose Health Information to medical examiners or funeral directors to permit them to carry out their duties.
Organ donor organizations: Consistent with applicable law, we may disclose Health Information to organ donor organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Marketing: We, or persons working with us, may contact you to provide information about health-related products or services that may be of interest to you. Your Health Information may also be a source of data for our Practice’s planning and marketing activities. If we desire to provide Health Information to third parties for their marketing activities, we will ask for your authorization in writing before doing so.
Food and Drug Administration (FDA): We may disclose to the FDA Health Information relative to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recall, repair, or replacement.
Workers compensation: We may disclose Health Information 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.
Public health: We may disclose your Health Information to public health or legal authorities charged with improving health (for example, by preventing or controlling disease, injury, or disability) when and to the extent required or permitted by law.
National security/military service: We may disclose Health Information for national security purposes. We may also disclose Health Information about Armed Forces personnel to appropriate military authorities in certain circumstances.
Correctional institution: If you are an inmate of a correctional institution, we may disclose to the institution or agents of this institution Health Information necessary for your health and the health and safety of others.
Law enforcement/Prevention of harm/Required by law: We may disclose Health Information for law enforcement purposes as required by law or in response to a valid subpoena or court order; or where, in our judgment, we believe there may be a threat of serious bodily harm to a patient or other person. Also, Federal or state law may require that your Health Information be released to an appropriate health oversight agency, public health authority, or other organization in certain circumstances.
THE POLICIES IN OUR NOTICE WERE FIRST EFFECTIVE AS OF: January 1, 2004, and last revised November 22, 2004.