GOLDSMITH MEDICAL CO. 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 GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
We are required by applicable federal and state law to
protect and maintain the privacy of your health information. We are also required to give
you this Notice explaining our privacy practices, our legal duties with respect to your
health information, and your rights concerning your health information.
We must follow the privacy practices that are described
in this Notice while it is in effect. We reserve the right to change the terms of this
Notice at any time. Any changes to this Notice will be effective immediately and will
apply to all health information that we maintain. If we make changes to this Notice, we
will post the new Notice on our website at www.goldsmithmedical.com
You may always obtain a copy of our Notice currently in effect on our website or by
contacting our Privacy Officer, Carolynn Boehmer, at (314) 426-5400.
This Notice takes effect on April 14, 2003 and will
remain in effect until we replace it.
If, at any time, you have questions about this Notice or
about our privacy practices, you may contact our Privacy Officer, Carolynn Boehmer, by
telephone at (314) 426-5400; or by mail or in person at 1926 Innerbelt Business Center
Drive, St. Louis, Missouri 63114.
OUR USES AND DISCLOSURES OF YOUR HEALTH
INFORMATION
Treatment: We may use or disclose your health
information to a physician or other health care provider providing treatment to you. This
may include communicating with health care providers regarding your condition, treatment,
and coordinating and managing your health care.
Payment: We may use and disclose your health
information, including, without limitation, your name, address, date of birth, Social
Security Number and diagnosis to your insurance carrier in order to obtain payment for the
services we provide to you. We also may disclose your health information, as necessary, to
others to seek payment for services we have rendered (such as collection agencies and
consumer reporting agencies).
Example: We provide you with certain equipment
which your physician prescribes. We then provide the identifying information and medical
information about you which your insurance company requires in order for us to receive
payment for the equipment we provided to you.
Health Care Operations: We may use and disclose
your health information in connection with our health care operations. Health care
operations include quality assessment and improvement activities, reviewing the competence
or qualifications of health care professionals, evaluating practitioner and provider
performance, conducting training programs, accreditation, certification, licensing or
credentialing activities.
Example: You or your physician raise concerns
regarding a piece of equipment we provide to you. We review your health information with
your physician and with our internal quality assurance staff in order to help evaluate the
equipment provided to you.
Your Authorization: You may give us written
authorization to use your health information or disclose it to anyone for any
purpose. This authorization must be in writing on our Patient Authorization form, a copy
of which you may obtain from our Privacy Officer. If you give us an authorization, you may
revoke it in writing at any time. Your revocation will not affect any use or disclosures
permitted by your authorization while it was in effect. Unless you give written
authorization to us on our Patient Authorization form, we cannot use or disclose your
health information for any reason except for those reasons described in this Notice.
To You and Your Family and Friends: We must
disclose your health information to you, as described in the Patient Rights section of
this Notice. We may disclose your health information to a family member, friend or other
person to the extent necessary to help with your health care health care, but only if you
agree that we may do so or if we may reasonably infer from the circumstances that you
would not object.
Marketing Health-Related Services: We will not use
your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health
information when we are required to do so by law.
National priority uses and disclosures: When
permitted by law, we may use or disclose your health information for various activities
that are recognized as "national priorities." In other words, the government has
determined that under certain circumstances (described below), it is so important to
disclose health information that it is acceptable to disclose health information without
the individual’s permission. We will only disclose health information about you in
the following circumstances when we are permitted to do so by law. Below are brief
descriptions of the "national priority" activities recognized by law.
- Threat to health or safety:
We may use or disclose
health information about you if we believe it is necessary to prevent or lessen a serious
threat to health or safety.
- Public health activities:
We may use or disclose
health information about you for public health activities. Public health activities
require the use of medical information for various activities, including, but not limited
to, activities related to investigating diseases, reporting child abuse and neglect,
monitoring drugs or devices regulated by the Food and Drug Administration, and monitoring
work-related illnesses or injuries.
- Abuse, neglect or violence:
We may disclose your
health information to the Department of Social Services if you are a nursing home resident
and we reasonably believe that you may be a victim of abuse, neglect or violence.
- Health oversight activities:
We may disclose your
health information to a health oversight agency – which is basically an agency
responsible for overseeing the health care system or certain government programs. For
example, a government agency may request information from us while they are investigating
possible insurance fraud.
- Court proceedings:
We may disclose your health
information to a court or pursuant to a subpoena. For example, we would disclose medical
information about you to a court if a judge orders us to do so.
- Law enforcement:
We may disclose your health
information to a law enforcement official for specific law enforcement purposes. For
example, we may disclose limited medical information about you to a police officer if the
officer needs the information to help find or identify a missing person, or to locate a
suspect.
- Coroners and others:
We may disclose medical
information about you to a coroner, medical examiner, or funeral director for identifying
a deceased person, determining cause of death, or carrying out their duties as required by
law.
- Organ Donation:
If you are an organ donor, we may
release your health information to organizations that handle organ procurement or
transplantation, or to an organ donation bank, as necessary to facilitate organ donation
and transplantation.
- Workers’ compensation:
We may disclose your
health information in order to comply with workers’ compensation laws.
- Certain government functions:
We may use or disclose
your health information for certain government functions, including but not limited to
military and veterans’ activities and national security and intelligence activities.
We may also use or disclose health information about you to a correctional institution in
some circumstances.
PATIENT RIGHTS
Copy of Notice: You have the right to have a paper
copy of our Notice of Privacy Practices at any time. If you would like a paper copy of our
Notice currently in effect, contact our Privacy Officer, Carolynn Boehmer, at (314)
426-5400 or at 1926 Innerbelt Business Center Drive, St. Louis, Missouri 63114. You also
may review, access and print-out a copy of our current Notice of Privacy Practices from
our website at www.goldsmithmedical.com
Access: You have the right to look at or get
copies of your health information, with limited exceptions. Requests to obtain access to
your health information must be in writing and directed to our Privacy Officer.. We will
charge you a reasonable cost-based fee for expenses for copies. If copies are requested,
we will charge you 35 cents for each page and postage if you want the copies mailed to
you. If necessary, you may contact our Privacy Officer if you have any questions about
costs for copies.
Disclosure Accounting: You have the right to
receive a list of instances in which we or our business associates disclosed your health
information for purposes, other than treatment, payment, health care operations and
certain other activities, for the last 6 years, but not before April 14, 2003. This
request for an accounting must be in writing and directed to our Privacy Officer. If you
request this accounting more than once in a 12 month period, we may charge you a
reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we
place additional restrictions on our use or disclosure of your health information. This
request must be in writing and directed to our Privacy Officer. We are not required to
agree to these additional restrictions, but if we do, we will abide by our agreement
(except in an emergency treatment situation).
Alternative Communication: You have the right to
request that we communicate with you about your health information by alternative means or
to alternative locations. (You must make your request in writing to our Privacy Officer.)
Your request must specify the alternative means or location.
Amendment: You have the right to request that we
amend your health information. Your request must be in writing and directed to our Privacy
Officer. Your request must explain why the information should be amended. We may deny your
request under certain circumstances and will explain our denial to you in writing.
Questions and Complaints: If you want more
information about our privacy practices or have questions or concerns, please contact our
Privacy Officer.
If you are concerned that we may have violated your
privacy rights, or you disagree with a decision we made about access to your health
information or in response to a request you made to amend or restrict the use or
disclosure of your health information or to have us communicate with you by alternative
means or at alternative locations, you may complain to us in writing. You also may submit
a written complaint to the U.S. Department of Health and Human Services. You will not be
retaliated against in any way for filing a complaint with us or with the federal
government.
We support your right to the privacy of your health
information and to your right to file a written complaint. We will not take any action
against you or change our treatment of you in any way if you choose to file a complaint
with us or with the U.S. Department of Health and Human Services.
To file a written complaint with us, you may mail,
hand-deliver or fax your complaint to us at the following address or fax number:
Carolynn Boehmer
Privacy Officer
Goldsmith Medical Co.
1926 Innerbelt Business Center Drive
St. Louis, MO 63114
Fax: (314) 426-5550
To file a written complaint with the U.S. Department of
Health and Human Services, you may mail, fax or e-mail your written complaint to the
following address, fax number or e-mail address:
Office of Civil Rights
U.S. Department of Health and Human Services
601 East 12th Street—Room 248
Kansas City, Missouri 64106
Fax: (816) 426-3686
e-mail: OCRComplaint@hhs.gov
