Highlands Oncology Group, Fayetteville, Arkansas

Highlands Oncology Group
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NOTICE OF PRIVACY PRACTICES

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.


RIGHTS

Patients of Highlands Oncology Group have the right to the following:
  • You have the right to request restrictions on certain uses and disclosures of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to any restriction and will advise you if this is the case.

  • You have the right to receive confidential communications of your protected health information and may request to receive information from us by alternative means or at alternate locations.

  • You have the right to inspect and copy protected health information about you. If you desire to review and inspect your medical record, a request to do so may be made in writing to the Privacy Officer whose name and telephone number are listed below. You will receive information on the dates available for inspection of your record within 30 days of your request. If you desire to copy any part or all of your medical record, you may also make a request for copies to the Privacy Officer. The copies will be made and forwarded to you by mail within 30 days of receipt of your request. A charge of $20.00 will be assessed to cover the costs of copying the material.

  • You have the right to request amendments or revisions to your protected health information and to receive a response to your request for an amendment or revision. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

  • You have the right to receive an accounting of disclosures of protected health information that were provided without your written authorization. This accounting will be provided one time per year at no cost to you.

  • You have the right to obtain a paper copy of this notice if this form is provided electronically.
RIGHTS AND RESPONSIBILITIES OF HIGHLANDS ONCOLOGY GROUP
  • Highlands Oncology Group has the right to refuse to agree to a requested restriction on uses or disclosure of protected health information.

  • Highlands Oncology Group is required by law to maintain the privacy of protected health information of each of our patients.

  • Highlands Oncology Group is required by law to provide a copy of this notice of privacy practices to you as it relates to your protected, confidential patient information.
USES OR DISCLOSURES
    Highlands Oncology Group shall from time to time provide information about you without requesting specific authorization for treatment, payment and healthcare operations. This is not a complete listing, but is provided as an example of how the information may be used:

    TREATMENT
    The physicians of the clinic may confer about your needs and will share pertinent information about you as needed for on call coverage. Your physician may share protected health information about you with hospitals and other health care providers.

    PAYMENT
    Information about your health will be shared with your insurance company to provide the information they require in order to pay your claim for the services rendered. We may also disclose medical information to your insurance company to obtain prior authorization for treatment and procedures. We may also disclose information about your health or medical billing information to third party billers or outside medical services.

    HEALTH CARE OPERATIONS
    Highlands Oncology Group may use health information for operations and activities such as quality control, quality assurance, and financial planning that are necessary to provide efficient and quality care for our patients.

    APPOINTMENT REMINDERS
    The Highlands Oncology Group will contact you by telephone to remind you of your scheduled appointments. If you do not wish to have these reminders by telephone, please contact the receptionist of the Privacy Officer.

    MARKETING AND FUND RAISERS
    Highlands Oncology Group may contact you by phone or mail regarding certain marketing or fund raising efforts.
SITUATIONS WHICH DO NOT REQUIRE AUTHORIZATION
    We are allowed to release medical information about you to the following without an authorization:

    PUBLIC HEALTH ACTIVITIES
    Highlands Oncology Group may disclose medical information about you for public health activities such as control of disease, injury, or disability, reporting of births and deaths, reporting of child abuse or neglect, reporting of medication adverse events, and in situations related to defective medical products.

    ORGAN AND TISSUE DONATION
    Highlands Oncology Group may disclose medical information to organizations that handle organ transplantation if you are an organ donor.

    MILITARY AND VETERANS
    Highlands Oncology Group may release medical information about you to military authorities if you are a member of the armed forces for activities deemed necessary by appropriate military command authorities, for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or to foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

    WORKER’S COMPENSATION
    Highlands Oncology Group may disclose medical information about you for worker’s compensation programs if you have a work related injury.

    AVERTING SERIOUS THREAT TO HEALTH OR SAFETY
    Highlands Oncology Group is required to disclose medical information when necessary to prevent a serious threat to your health and safety or the health and safety of others.

    HEALTH OVERSIGHT
    Highlands Oncology Group may disclose medical information to a health oversight agency such as audits, investigations and inspections.

    LAW ENFORCEMENT
    Highlands Oncology Group may disclose medical information to law enforcement officials to the extent that such use or disclosure is required by law.

    CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
    Highlands Oncology Group may disclose medical information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death.

    NATIONAL SECURITY
    Highlands Oncology Group may disclose medical information to federal officials for intelligence and other national security activities as required by law.

    INMATES
    If you are an inmate, Highlands Oncology Group may disclose medical information about you to the institution or official to which you are assigned.
SITUATIONS WHICH REQUIRE AUTHORIZATION

Other uses and disclosures of medical information will be made only with your specific, written authorization. You have the right to revoke an authorization at any time except in the instance where entity has already taken action in reliance on this authorization.

COMPLAINTS

If you have a question or complaint about the way your protected health information is handled, please contact the Privacy Officer whose name is listed below.

PRIVACY OFFICER

Elaine Lahay
Highlands Oncology Group 3232 N. North Hills Blvd. Fayetteville, AR 72703 (479) 587-1700 You may also file complaints with the Secretary of the Federal Department of Human Services. You will not be penalized or suffer retaliation if you file a complaint regarding a known or suspected violation of your privacy rights.

REVISION OF NOTICE

This notice may be revised or updated from time to time. If the notice is revised or changed, you will be provided a copy of the revised notice. Any revision of the notice will apply to all protected health information that is maintained by Highlands Oncology Group. We will also post any revised notice in the front office of Highlands Oncology Group.

EFFECTIVE DATE

This notice is effective on January 1, 2003.



Acknowledgement of Receipt

NOTICE OF PRIVACY PRACTICES

Your signature acknowledges that you have received a copy of the
Notice of Privacy Practices.

Patient Name _________________________________________________

Signature of Patient ____________________________________________

Date Signed __________________________________________________

Patient Representative (if applicable) _______________________________

Relationship of Representative ____________________________________

T O P


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Highlands Oncology Group
All Rights Reserved.