of Privacy Practices
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.
Pursuant to the Health Insurance Portability and Accountability Act
of 1996 (HIPAA), you have a right to adequate notice of the uses and
disclosures of your protected health information ("PHI") (i.e.,
information that discloses your identity or leads to disclosure of your
Identity) that may be made by Oracle Imaging Services and Neil Chafetz,
MD, Inc. ("OIS/NIC"). You are also entitled to notice of your
rights and the duties of OIS/NIC with respect to your personal health
information. We respect your right to privacy. We create paper and electronic
records about your health and the care we provide. Your personal health
information is confidential and this notice is intended to help you
understand how OIS/NIC uses and discloses your personal health information
and what rights you have with respect to your medical information.
REQUIRED BY LAW:
OIS/NIC has the following duties with respect to your personal health
information: I) We are required by law to maintain the privacy of your
personal health information. 2) We must provide you with notice of our
legal duties and privacy practices with respect to personal health information.
3) We must abide by the terms of the notice of privacy practices that
is currently in effect.
HOW WE MAY USE & DISCLOSE YOUR INFORMATION:
The following describes how OIS/NIC is permitted by law to share your
personal health information with others in order to provide you with
medical care. This notice does not describe every use or disclosures
OIS/NIC makes. It is intended as a general overview.
Treatment: We may need to share information
about you in order to provide medical care to you. For example, we may
share information with other physicians, nurses or healthcare professional
entering information into your medical records relating to your medical
care and treatment. We may share information about you including x-rays,
prescriptions and requests for lab work.
We may need to disclose information about this treatment, procedures
or care our practice provided to you in order to bill and receive payment
for services we provided. We may share this information with an insurance
company or any third party responsible for payment. We may also need
to disclose personal health information about you with your health plan
and/or referring physician in order to obtain prior authorization for
treatment, to determine whether payment for the treatment is covered
by your plan or to facilitate payment. Healthcare Operations. In order
to help us run OIS/NIC more efficiently and provide better patient care,
we may use and disclose your personal health information to business
associates who need to use or disclose your information to provide a
service for our medical practice, such as our billing company or software
vendors who provide assistance with data management on our behalf.
by Law: We will disclose medical information
related to you if required to do so by state, federal or local law.
Public Health Activities / Risks. Your medical information may be disclosed
to a public health authority that is authorized by law to collect or
receive such information for public health activities. Certain disclosures
may be made for public health activities in the following circumstances:
I) to prevent or control disease, injury or disability; 2) to report
births or deaths; 3) to report child abuse or neglect, 4) to report
reactions to medications or product defects; 5) to notify individuals
of product recalls; 6) to notify a person who may have been exposed
to a communicable disease or at risk of contracting or spreading a disease
or condition; 7) if OIS/NIC reasonably believes a person is the victim
of abuse, neglect, or domestic violence, we may disclose personal health
information to the appropriate authority. We will only make this disclosure
if you agree to the disclosure or we are required or authorized to do
so by law without your permission.
Reminders or Treatment Alternatives:
OIS/NIC may use and disclose medical information about you to provide
you with reminders that you are due for care or you have an upcoming
appointment. We may also wish to provide you with Information on treatment
alternatives or other health related benefits that may be of interest
to you. We may contact you by phone, fax or e-mail. We will make every
effort to protect your privacy when leaving a message for you and try
to reveal as little confidential information as possible (e.g., when
leaving a message on your answering machine that may be heard by others).
Under certain circumstances, OIS/NIC may use or disclose your personal
health information for research purposes. OIS/NIC may also disclose
information about you in preparing to conduct research (e.g., to help
them find patients who may be qualified to participate in a particular
study), but your information will not leave our practice. We will make
all attempts to make your information non-identifiable, but we may not
always be able to guarantee this. Worker's Compensation. We may release
medical information about you for work-related illness or injury as
it relates to workers compensation or other related programs.
Oversight Activities: Your personal
health information may be disclosed to federal, state or local authorities
as part of an investigation or government activity authorized by law.
This may include audits, civil, administrative or criminal investigations,
inspections, licensure or disciplinary actions or other activities necessary
for the oversight of the health care-system, government benefit programs
and compliance with government regulatory programs or civil rights laws.
Enforcement: We may disclose your
personal health information to law enforcement individuals if we are
required to do so by law. We may also disclose medical information about
you in compliance with a court order, warrant or subpoena or summons
issued by the court We will make our best effort to contact you about
these types of requests so that you can obtain an order restricting
or prohibiting disclosures of the information requested We may also
use such information to defend ourselves in actions or threatened actions
that may be brought against our practice.
Abuse or Neglect:
We may disclose your health information to appropriate authorities is
we reasonably believe that you are a possible victim of abuse, neglect
or domestic violence or the possible victim of other crimes. We may
disclose your health information to the extent necessary to avert a
serious threat to your safety or the health or safety of others.
We may disclose to military authorities the health information if Armed
Forces personnel under certain circumstances. We may disclose to authorized
federal officials health information required for lawful intelligence,
counterintelligence, and other national security activities. We may
disclose to correctional institution or law enforcement officials having
lawful custody of protected health information of inmate or patient
under certain circumstances.
To Coroners, Funeral Directors, and for Organ
Donation: Our practice may disclose
protected health information to a coroner or medical examiner for the
purpose of (I) identification, (2) determination of cause of death,
or (3) performance of the coroner or medical examiner's other duties
as authorized by law. Protected health information may also be used
and disclosed for the purpose of cadaver organ, eye or tissue donation.
Other than the circumstances described above: OIS/NIC will not
disclose your health information unless you provide written authorization.
You may revoke your authorization in writing at any time except to the
extent that OIS/NIC has take action in reliance upon the authorization.
AND DISCLOSURES THAT YOU CAN AGREE OR OBJECT TO:
Others Involved in your Healthcare. Unless you object, 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, 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 any 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. If you are incapacitated or in an emergency situation,
our practice may exercise its professional judgment to determine if
the disclosure is in your best interests.
RIGHTS: You have certain rights regarding
your protected health information under the HIPAA privacy regulations.
TO RECEIVE PERSONAL HEALTH INFORMATION CONFIDENTIALLY:
You have the right to receive confidential communications of your personal
health information by alternate means or at alternated locations. For
example, if you would like us only to communicate with you at home,
and never at your workplace, you may request this of OIS/NIC. You must
make this request in writing but do not need to disclose the reason
for your request We will attempt to accommodate all reasonable requests.
Please be specific as to how or where you wish us to communicate with
TO INSPECT AND COPY: You have the
right to inspect and copy your medical records. This includes medical
and billing records. Records related to your care may also be disclosed
to an authorized person such as a parent or guardian upon proof of a
legitimate legal relationship. You must submit your request in writing
to inspect and copy your records. If you would like us to copy your
records, we may charge you fees for the cost of copying records, mailings
or other nominal costs associated with your request.
TO AMEND: During the time that OIS/NIC
holds your protected health information, you may request an amendment
of your information in a designated record set OIS/NIC may deny your
request in some instances. However, should our practice deny your request
for amendment, you have the right to file a statement of disagreement
with the practice. In turn, OIS/NIC may develop a rebuttal to your statement
If it does so, OIS/NIC will provide you with a copy of the rebuttal.
Requests for amendment must be submitted in writing to the practice's
Privacy Officer. Your written request must supply a reason to support
the requested amendments.
TO AN ACCOUNTING OF USES AND DISCLOSURES:
You have the right to receive an accounting of the disclosures of your
personal health information that our practice makes for purposes other
than treatment, payment or healthcare operations. All requests must
be submitted in writing. All requests must be for disclosures dated
AFTER April 14, 2003. All requests must state a time not longer than
six (6) years back. You must state whether you would like the accounting
electronic or paper form. One request in a twelve-month period will
be provided to you at no charge. We may charge you a fee for all additional
requests within a twelve-month period. We will notify you as to the
cost. You have the right to obtain a paper copy of this Notice. Our
practice will provide a separate paper copy of this Notice upon request
even if you have already been given a copy of it or have agreed to review
PRACTICE'S DUTIES: Our practice is
required to ensure the privacy of your health information and to provide
you with this Notice of your rights and the practice's duties and procedures
regarding your privacy. The practice must abide by the terms of this
Notice, and they may be amended periodically. The practice reserves
the right to change the terms of this Notice and to make the new Notice
provisions effective for all protected health information that OIS/NIC
collects and maintains. If the practice alters its Notice, OIS/NIC will
provide a copy of the revised Notice through regular mail or in-person
If you believe that your privacy rights have been violated, you have
the right to relate complaints to the practice and to the Secretary
of the Department of Health and Human Services. You may provide complaints
to the practice verbally or in writing. Such complaints should be directed
to the practice's Privacy Office. OIS/NIC encourages you to relate any
concerns you may have regarding the privacy of your information and
you will not be retaliated against in any way for filing a complaint.
PERSON: The practice's contact person
regarding the practice's duties and your rights under the HIPAA privacy
regulations is the Privacy Officer. The Privacy Officer can provide
information regarding issues related to this Notice by request. Complaints
to the practice should be directed to the Privacy Officer at the following
address: Oracle Imaging Services, Inc., 1360 W. 6th St., West Building, Suite 100, San
Pedro, CA 90732 ATTN: Privacy Officer (310) 833-2233.