NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
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.
Our office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment and applying for future care or treatment. It also includes billing documents for those services.
Example of uses of your health information for treatment purposes are:
Example of use of your health information for payment purposes:
Example of use of your information for Health Care Operations:
Your Health Information Rights
The health and billing records we maintain are the physical property of Premier Diagnostic Imaging, LLC. You have the following rights with respect to your Protected Health Information.
1. Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office – we are not required to grant the request but we will comply with any request granted;
2. Obtain a paper copy of Privacy practices for Protected Health Information (“Notice”).
3. Right to inspect and receive a copy your health record and billing record in paper or in electronic form that is available – you may exercise this right by delivering the request in writing to our office using the form we provide to you upon request. In limited circumstances, your request may be denied. You may appeal a denial of access to your protected health information and the request may be reviewed again.
4. Right to request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office using the form we provide to you upon request. (The physician or other health care provider is not required to make such amendments); you may file a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.
5. Right to receive an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form we provide to you upon request. An accounting will not include internal uses of information for treatment, payment or operations, disclosures made to you or made at our request or disclosures made to family members in the course of providing care;
6. Right to confidential communication by requesting that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office using the form we give you upon request.
7. Right to request a restriction to your healthcare plan if you are paying in full and if it is not for treatment, payment or operations.
If you want to exercise any of the above rights, please contact Jennifer Adams at Premier Diagnostic Imaging at 931-528-1800, in person or in writing, during normal business hours. She will provide you with assistance on the steps to take to exercise your rights.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. 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:
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
In the case of fundraising:
The office is required to:
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.
TO REQUEST INFORMATION OR FILE A COMPLAINT
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you make contact Penny Jackson, Director of Imaging Services at 931-528-1800.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Penny Jackson whose street address and e-mail address is 315 N. Washington Avenue, Suite 103, Cookeville, TN 38501 and email@example.com. You may also 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/ .
The Following is a List of Other Uses and Disclosures Allowed by the Privacy Rule
We may contact you to provide you with appointment reminders, with information about treatment alternatives or with information about other health-related benefits and services that may be of interest to you.
Notification – Opportunity to Agree or Object
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member; personal representative, or other person responsible for your care, about your location and about your general condition or your death.
Communication with Family – Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency. We may share medical information about unemancipated minors with a parent, legal guardian, or other person acting in loco parentis if not otherwise limited by law
We may use and disclosure your protected health information to assist in disaster relief efforts.
Opportunity to Agree or Object Not Required
PUBLIC HEALTH ACTIVITIES
Controlling Disease – As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
Child Abuse & Neglect – We may disclose protected health information to public authorities as allowed by law to report child abuse or neglect.
Food and Drug Administration (FDA) – We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
Work related injury or illness. We may disclose work related injury or illness your protected health information pertaining to the work related injury or illness to the employer if the employee needs the findings in order to comply with OSHA regulations.
Victims of Abuse, Neglect or Domestic Violence
We can disclose protected health information to governmental authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment the doctor believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight agencies to include audits, civil, administrative or criminal investigations; inspections; licensures or disciplinary actions, and for similar reasons related to the administration of healthcare.
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, or as directed by a proper court order or administrative tribunal, provided that only the protected health information released is expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process.
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, including laws that require reporting of certain types of wounds or other physical injury.
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
ORGAN PROCUREMENT ORGANIZATIONS
Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.
We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
THREAT TO HEALTH AND SAFETY
To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
FOR SPECIALIZED GOVERNMENTAL FUNCTIONS
We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES: We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities as authorized by law.
PROTECTIVE SERVICES TO THE PRESIDENT AND OTHERS: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigation.
OTHER USES AND DISCLOSURES
This Notice is on our website at premierdiagnostic.com
Effective Date: April 14, 2003
Revised: January 2022