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Commonly Requested Forms
Family MedCenters, PA
Effective Date: April 14, 2003


Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for your future care or treatment, and billing-related information. Such records are necessary for the healthcare provider to provide you with quality care and to comply with certain legal requirements.

We are committed to protecting the confidentiality of our records containing information about you. This notice applies to protected health information about you. Other healthcare providers from whom you obtain care and treatment may have different policies or notices regarding the use and disclosure of your health information created or received by the provider. Also, health plans in which you participate may have different policies or notices concerning information they receive about you.

This notice will tell you about they ways in which we may use and disclose health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.
We are required by law to maintain the privacy of your health information; give you this notice of our legal duties and privacy practices and make a good faith effort to obtain your acknowledgment of receipt of this notice; and follow the terms of the notice that is currently in effect.

The following categories describe different way that we are permitted to use and disclose health information without a specific authorization from you.
For Treatment: We may use information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at the Family MedCenters, PA. For example, a doctor treating you for a broken leg may need to know if you have diabetes, because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the Family MedCenters, PA may also share information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. We may also disclose health information about you to other health care providers who request such information for purposes of providing medical treatment to you.

For Payment: We may use and disclose health information about you so that the treatment and services you receive at our offices may be billed to and payment may be collected from you, an insurance company, or other third party. For example, we may need to give your health plan information about surgery you received so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We also may provide information about you to other health care providers, health plans, or health care clearinghouses to assist them in obtaining payment for treatment and service they provided to you.

For Health Care Operations: We may use and disclose health information about you for our internal operations. These uses and disclosures are necessary to run our office and to make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. In addition, we may disclose health information about you to another health care provider, health plan, or health care clearinghouse with which you also have had a relationship for certain internal operations of that entity.

Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care at Family MedCenters, PA. Unless you direct us to do otherwise, we may leave messages on your telephone answering machine identifying our office and asking for you to return our call and may send you appointment reminders through the mail using a postcard.

Treatment Alternatives/Other Benefits and Services:
In addition, we may use your information to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fundraising Activities: We may use health information about you to contact you in an effort to raise money for Family MedCenters, PA and its operations. We may disclose health information to a foundation related to Family MedCenters, PA so that the foundation may contact you in raising money for Family MedCenters, PA. We only would release contact information, such as your name, address, phone number and dates you received treatment or services at our offices. If you do not want us to use or disclose your health information for fundraising efforts, you must notify us in writing at the address set forth at the end of this notice.

Business Associates: There are some services provided in our organization through contracts or arrangements with business associates. For example, we may contract with a copy service to make copies of your health record. When these services are contracted, we may disclose your health information to our business associate so they can perform the job we’ve asked them to do. To protect your health information, however, we require our business associates to appropriately safeguard your information.

Individuals Involved In Your Care of Payment For Your Care: We have policies and procedures that provide for the release of information about your care or payment for such care to a member of your family, a relative, a close friend, or any other person when your are not present or able to give authorization for the release of information. If you are present for such a disclosure (whether in person or on a telephone call), we will either seek your verbal agreement to the disclosure or provide you an opportunity to object to it.

Research: We may use and disclose health information for research purposes, provided we have taken established measures to protect your privacy. For instance, we must obtain your authorization to use or disclose health information for research purposes unless such authorization requirement is altered or waived by an Institutional Review Board or other authorized privacy board or unless we enter into a data use agreement with the recipient of the information and only use or disclose information in a “limited data set” in accordance with such agreement.

As Required By Law: We may use or disclose your health information to the extent we are required to do so by federal, state, or local law. For example, we may disclose health information about you for the following purposes:
For judicial and administrative proceedings pursuant to legal authority;
To report information related to victims of abuse, neglect or domestic violence; and
To assist law enforcement officials in their law enforcement duties.
To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you if we believe in good faith that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health and safety or that of the public or another person. Any disclosure, however, would only be to someone reasonably able to help prevent or lessen the threat. Organ and Tissue Donation: If you are an organ donor, we may use or disclose health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans: If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Employers: We may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of the information to your employer.

Worker’s Compensation: We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risk: We may disclose health information about you for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability or for other health oversight activities authorized by law, such as reporting reactions to medications or problems with product and notifying people of recalls of product they may be using.

Health Oversight Activities:
We may disclose health information to health oversight agency for that agency to carry out activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure, which are necessary for the government to monitor the health care system, government programs involving health care, and compliance with certain civil rights laws.

Lawsuits and Disputes: We may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release certain health information if asked to do so by a law enforcement official to assist such official in carrying out his or her duties, including such things as identifying or location a suspect, fugitive, material witness, or missing person or reporting a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors: We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients of Family MedCenters, PA to funeral directors as necessary for them to carry out their duties.

Government Functions:
We may release health information about you to authorized federal officials for government functions such as special investigations, intelligence, counterintelligence, and other national security activities authorized by law, including disclosures necessary for the protection of the President and other authorized individuals.

Inmates/Persons In Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official as necessary to allow them to carry out certain specified activities, including, but not limited to providing you with health care, protecting the health and safety of you and others, and protecting the security of the correctional institution.


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Family MedCenters cares about your privacy