THERAPRO
LLC NOTICE OF PRIVACY PRACTICES
Effective April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices apply
to Therapro LLC and each of its employees. All of
the entities will share personal health information
of patients as necessary to carry out treatment,
payment, and health care operations as permitted
by law.
We are required by law to maintain the privacy of
our patients' personal health information and to
provide patients with notice of our legal duties
and privacy practices with respect to personal health
information. We are required to abide by the terms
of this Notice for as long as it remains in effect.
We reserve the right to change the terms of this
Notice of Privacy Practices as necessary and to
make a new Notice effective for all personal health
information maintained by Therapro LLC. We are also
required to inform you that there may be a provision
of State law that relates to the privacy of your
health information that may be more stringent than
a standard or requirement under the Federal Health
Insurance Portability and Accountability Act. A
copy of any revised Notice of Privacy Practices
or information pertaining to a specific State law
may be obtained by mailing a request to the Privacy
Officer, Therapro LLC 9225 Kennedy Blvd. North Bergen,
NJ 07047.
USES
AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION
Authorization
and Consent: Except as outlined below, we
will not use or disclose your personal health information
for any purpose other than treatment, payment or
healthcare operations unless you have signed a form
authorizing the use or disclosure. You have the
right to revoke that authorization in writing unless
we have taken any action in reliance on the authorization.
Uses and Disclosures for Treatment: With your agreement,
we will make uses and disclosures of your personal
health information as necessary for your treatment.
Doctors and nurses and other professionals involved
in your care will use information in your medical
record and information that you provide about your
symptoms and reactions to your course of treatment
that may include procedures, medications, tests,
medical history etc.
Uses and
Disclosures for Payment: With your agreement,
we will make uses and disclosures of your personal
health information as necessary for payment purposes.
During the normal course of business operations,
we may forward information regarding your medical
procedures and treatment to your insurance company
to arrange payment for the services provided to
you. We may use your information to prepare a bill
to send to you or to the person responsible for
your payment.
Uses and Disclosures for Health Care Operations:
With your agreement, we will use and disclose your
personal health information as necessary, and as
permitted by law, for our health care operations,
which may include clinical improvement, professional
peer review, business management, accreditation
and licensing, etc. For instance, we may use and
disclose your personal health information for purposes
of improving the clinical treatment and patient
care.
Individuals
Involved In Your Care: With your written
or oral agreement we may from time to time disclose
your personal health information to designated family,
friends, and others who are involved in your care
or in payment of your care in order to facilitate
that person's involvement in caring for you or paying
for your care. If you are unavailable, incapacitated,
or facing an emergency medical situation and we
determine that a limited disclosure may be in your
best interest, we may share limited personal health
information with involved individuals without your
approval. We may also disclose limited personal
health information to a public or private entity
that is authorized to assist in disaster relief
efforts in order for that entity to locate a family
member or other persons that may be involved in
some aspect of caring for you.
Appointments
and Services:
We may contact you to provide appointment reminders
or information about your treatment or other health-related
benefits and services that may be of interest to
you. You have the right to request and we will accommodate
reasonable requests by you to receive communications
regarding your personal health information from
us by alternative means or at alternative locations.
For instance, if you wish appointment reminders
to not be left on voice mail or sent to a particular
address, we will accommodate reasonable requests.
You also have the right to request that we not send
you any future marketing materials and we will use
our best efforts to honor such request. You may
make your requests by sending your name and address
to Privacy Officer, 9225 Kennedy Blvd. North Bergen,
NJ 07047.
Research:
In limited circumstances, we may use and disclose
your personal health information for research purposes.
In all cases where your specific authorization is
not obtained, your privacy will be protected by
strict confidentiality requirements applied by an
Institutional review board which oversees the research
or by representations of the researchers that limit
their use and disclosure of patient information.
Other Uses
and Disclosures: We are permitted and/or
required by law to make certain other uses and disclosures
of your personal health information without your
consent or authorization for the following:
- any purpose required
by law.
- public health activities,
such as required reporting of disease, injury,
birth and death, or required public health investigations.
- if we suspect child
abuse or neglect; if we believe you to be a
victim of abuse, neglect, or domestic violence.
- to the Food and Drug
Administration to report adverse events, product
defects, or to participate in product recalls.
- to your employer when
we have provided health care to you at the request
of your employer;
- to a government oversight
agency conducting audits, investigations, or
civil or criminal proceedings.
- court or administrative
ordered subpoena or discovery request;
- to law enforcement
officials as required by law to report wounds
and injuries and crimes;
- to coroners and/or
funeral directors consistent with law;
- if necessary to arrange
an organ or tissue donation from you or a transplant
for you;
- if you are a member
of the military; we may also release your personal
health information for national security or
intelligence activities; and
- to workers' compensation
agencies for workers' compensation benefit determination.
RIGHTS
THAT YOU HAVE REGARDING YOUR PERSONAL HEALTH INFORMATION:
Access to
Your Personal Health Information: You have
the right to copy and/or inspect much of the personal
health information that we retain on your behalf.
All requests for access must be made in writing
and signed by you or your legal representative.
You may obtain a "Patient Access to Health
Information Form" from the front office person.
Amendments
to Your Personal Health Information: You
have the right to request in writing that personal
health information that we maintain about you be
amended or corrected. We are not obligated to make
all requested amendments but will give each request
careful consideration. All amendment requests, must
be in writing, signed by you or your legal representative,
and must state the reasons for the amendment/correction
request. If an amendment or correction request is
made, we may notify others who work with us if we
believe that such notification is necessary. You
may obtain an "Amendment Request Form"
from the front office person or individual responsible
for medical records.
Accounting
for Disclosures of Your Personal Health Information:
You have the right to receive an accounting
of certain disclosures made by us of your personal
health information after April 14, 2003. Requests
must be made in writing and signed by you or your
legal representative. "Accounting Request Forms"
are available from the front office person or individual
responsible for medical records. The first accounting
in any 12-month period is free; you will be charged
a fee for each subsequent accounting you request
within the same 12-month period. You will be notified
of the fee at the time of your request.
Restrictions
on Use and Disclosure of Your Personal Health Information:
You have the right to request restrictions on uses
and disclosures of your personal health information
for treatment, payment, or health care operations.
We are not required to agree to your restriction
request, but will attempt to accommodate reasonable
requests when appropriate. We retain the right to
terminate an agreed-to restriction if we believe
such termination is appropriate. In the event of
a termination by us, we will notify you of such
termination. You also have the right to terminate,
in writing or orally, any agreed-to restriction
by sending such termination notice to the individual
responsible for medical records.
Complaints:
If you believe your privacy rights have been violated,
you can file a complaint in writing with the Privacy
Officer, 9225 Kennedy Blvd. North Bergen, NJ 07047
. You may also file a complaint with the Secretary
of the U.S. Department of Health and Human Services
in Washington D.C. in writing within 180 days of
a violation of your rights. There will be no retaliation
for filing a complaint.
Workers'
Compensation: Medical information generated
for services provided to Workers' Compensation patients
is not covered by HIPAA. As such, Worker's Compensation
patients do not have the right to restrict, amend
or request an accounting of their Personal Health
Information generated for purposes of Workers' Compensation.
FOR FURTHER
INFORMATION: If you have questions or need
further assistance regarding this Notice, you may
contact the Privacy Officer 9225 Kennedy Blvd. North
Bergen, NJ 07047
(201) 869-2707.
_______________________________________________
Patient (or representative) Signature
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