HIPAA Notice of Privacy Practices

Section: Health Insurance and Accountability Act
Subject: Privacy Practices

Effective Date: April 2003

Revised: January 2007

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

THE PURPOSE OF THIS NOTICE

Urgent Cares of America (UCA) understands that medical information about you and your health is personal, and is committed to protecting your medical information. Your health information is contained in medical, billing and other records that are created by and are the physical property of UCA. This notice applies to such records.

This notice will tell you about the ways in which UCA may use and disclose medical information about you. It also describes your rights and certain obligations of UCA regarding the use and disclosure of medical information.

UCA is required by law to:

• ensure that medical information that identifies you is kept private;

• give you this notice of UCA’s legal duties and privacy practices at this office with respect to medical information about you; and

• adhere to the terms of the notice that is currently in effect.

WHO WILL FOLLOW THIS NOTICE.

This notice describes UCA’s privacy practices at all its locations and that of:

• All physicians, licensed health care personnel, employees, staff and other office personnel.

• Any independent health care professional who may provide services at our office and is authorized to enter information into your medical record.

• All students or trainees.

• Any persons or companies with whom UCA contracts for services to help operate our practice and who have access to our patients’ medical information.

All these persons and locations follow the terms of this notice. In addition, these persons, and locations may share medical information with each other for your treatment or UCA’s operations purposes and the purposes described in this notice. The independent health care professionals who provide care at this office and who have agreed to follow the terms of this Notice are not employees or agents of UCA, and UCA is not responsible for how they fulfill their professional responsibilities.

This notice applies to all of the records of your care and billing for care that are created at this office, whether made by UCA’s office personnel or your doctor or other independent health care personnel, who are responsible for their own actions. The independent health care personnel treating you may have different policies or notices regarding confidentiality and disclosure of your medical information that is created in their office or other locations outside this office.

HOW UCA MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that UCA uses and discloses medical information. For each category of uses or disclosures, there is an explanation and examples, though not every use or disclosure is listed.

• For Treatment. UCA may use medical information about you among the personnel in this office involved in your care to provide you with medical treatment, items or services. Different people in the office may share medical information about you to coordinate your needs, such as prescriptions, lab work and ultrasounds. UCA may use and disclose medical information to tell you about different ways to treat you, or health-related benefits or services that may be of interest to you. UCA also may need to disclose medical information about you to people outside our office who may be involved in your medical care before or after you leave the office, such as family members, hospitals, labs, home health agencies or medical equipment companies. UCA will only disclose medical information about you that identifies you to people outside our office, who are not currently involved in your care at our office, with your consent, or if such disclosures are required or permitted by law.

• For Payment. UCA may use and disclose medical information about you so that the treatment and services you receive at this office may be billed and payment may be collected from you, an insurance company or health plan, or a third party. For example, UCA may give your health plan information about your treatment to obtain prior approval to determine coverage or so your health plan will pay UCA or reimburse you. UCA will only disclose medical information about you that identifies you to people outside the office with your consent, or if such disclosures are required or permitted by law. If you have consented to a disclosure of medical information for the purpose of obtaining payment for the care provided to you, such disclosure may also result in giving information to other family members who are insureds on your policy or to someone who helps pay for your care, and your consent authorizes such disclosure.

• For Health Care Operations. UCA’s staff and business associates may use and disclose medical information about you to operate this office. For example, UCA may use medical information to call out your name in the waiting room or place your medical record in a slot on or beside your treatment room door, to review treatment and services or to evaluate the qualifications and performance of staff and physicians in caring for you. UCA may also disclose information to licensing authorities or offices who evaluate qualifications and review care to determine if UCA and its physicians can be licensed, credentialed, certified or approved under a health plan or to treat patients at a particular facility. UCA may also combine your medical information and other patients’ medical information from other practices for comparison and improvements in the care and services that UCA offers. UCA will remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who you are. UCA may contract with other professionals or companies, such as medical record transcription services, consultants, financial advisors or legal counsel, to help us run the practice and who have agreed to follow our Notice.

• Contacting You. Unless UCA has agreed in writing to your written request to handle these matters differently, UCA may use and disclose medical information to leave you a message or send you a letter concerning an appointment, to let you know lab results or prescriptions are ready, to ask you to call concerning your care or your patient account. UCA will use the contact information that you provide.

• Individuals Involved in Your Care and Disaster Relief. UCA may disclose medical information about you to a friend or family member who is involved in your medical care, unless you object. In addition, UCA may disclose medical information about you to an entity assisting in a disaster relief effort so that relief agencies and your family can be notified about your condition, status, and location. You can object to these disclosures by notifying UCA that you do not wish any or all individuals involved in your care or relief agencies to receive this information. If you are not present or cannot agree or object, UCA will use our professional judgment to decide whether it is in your best interest to disclose relevant information to someone who is involved in your care or to an entity or person assisting in a disaster relief effort.

• Research. Under certain circumstances, UCA may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. UCA will obtain your written consent if the researchers will know who you are. Medical information about you that has had all identifying information removed may be used for research without your consent.

WHEN DISCLOSURE MAY BE REQUIRED BY LAW WITHOUT YOUR AUTHORIZATION:

The following are examples of when UCA may disclose medical information about you when required to do so by federal, state, or local law:

• To Avert a Serious Threat to Health or Safety. UCA may use and disclose medical information about you when necessary to prevent or lessen a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would be to someone reasonably able to help prevent the threat.

• Organ and Tissue Donation. If you are an organ or tissue donor, UCA is required by law to provide medical information about you upon request after your death to the person or entity who receives the organ or tissue donation.

• Workers’ Compensation. UCA may release without your consent medical information about a work related injury for which UCA is treating you for workers’ compensation or similar programs under appropriate circumstances.

• Public Health Risks. UCA may disclose without your consent medical information about you for public health activities. These activities generally include the following:

                    -to prevent or control disease, injury, or disability;
                    -to report births and deaths;
                    -to report suspected abuse or neglect as required by law;
                    -to report to the FDA or other appropriate authorities or persons adverse reactions to                          medications or problems with products;
                    -to notify people of recalls of products they may be using; and
                    -to notify a person who may have been exposed to a disease or may be at risk for                               contracting or spreading a disease or condition.

• Health Oversight Activities. UCA may disclose without your consent medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, UCA may disclose medical information about you in response to a court or administrative order. UCA also may disclose medical information about you in response to a subpoena or other lawful process by someone else involved in the dispute by furnishing your medical records or information under seal to the court. Copies of your medical record under seal may only be opened by the parties to the case or their attorneys unless a judge orders otherwise.

• Law Enforcement. UCA may release without your consent medical information if asked to do so by a law enforcement official:

                    -In response to a court order, grand jury demand, or search warrant;
                    -About a death or injury we believe may be the result of criminal conduct; or
                    -About suspected criminal conduct at our office.

• Coroners, Medical Examiners, and Funeral Directors. UCA may release without your consent medical information requested by a coroner or medical examiner. UCA may also release information about the identity of patients to funeral directors.

• Security, Intelligence Activities, and Protective Services. UCA may release without your consent medical information about you to authorized federal or state officials for intelligence, counterintelligence, and other governmental activities authorized by law. UCA may disclose without your consent 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 to conduct special investigations.

• Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, UCA may release without your consent medical information about you to the correctional institution or law enforcement official with custody of you on behalf of the correctional institution if necessary: (1) for UCA to provide you with health care; (2) to protect your health and safety; (3) to obtain payment; or (4) for operations of UCA. If you are in the custody of the Department of Correction (“DOC”) and the DOC requests your medical records, UCA is required to provide the DOC with access to your records.

OTHER SITUATIONS

• Behavioral Health Care. Regardless of the other parts of this Notice, any information relating to alcohol and drug treatment or other behavioral health care treatment, including psychotherapy notes, will not be disclosed outside the office except as authorized by you in writing, pursuant to a court order, or as required by law. Private notes a licensed mental health professional has decided to make about a session with you, keep in his or her personal files, and designate as psychotherapy notes will not be disclosed to personnel working within our office, other than to the person who wrote the notes, except for training purposes or to defend a legal action brought against UCA and its employees, unless you have properly authorized such disclosure in writing.

• Minors.

A parent, guardian, or other person with authority to act for a minor may have access to and decide the use and disclosure of protected health information concerning a minor patient, except when:

(1) A custody order or agreement provides otherwise;

(2) A court order provides otherwise;

(3) There is a reasonable basis to suspect abuse or neglect of the minor and providing such information or authority to the parent, guardian, or other person acting for a minor is reasonably believed to present a risk of injury or harm to the minor; or

(4) The minor has the right to and does obtain health care on his or her own behalf as is permitted in the following cases:

    (a) For outpatient diagnosis or treatment of emotional illness or substance abuse;

    (b) For diagnosis or treatment of pregnancy (not abortion);

    (c) For diagnosis or treatment of sexually transmitted diseases.

In some limited circumstances, such as an emergency or if the parent or guardian contacts the Physician, the Physician may choose to disclose such information to the parent or guardian;

(5) The parent or guardian has agreed that such information will be confidential between the minor and the Physician.

OTHER USES OF MEDICAL INFORMATION.

Other uses and disclosures of medical information not covered by this notice will be made only with your written permission or as required by law. If you provide UCA permission to use or disclose medical information about you, you may revoke or discontinue that permission, in writing, at any time. Your revocation will be effective as of the end of the day on which you provide it in writing to UCA. If you revoke your permission, UCA will no longer use or disclose medical information about you for the purposes that you had authorized in writing. You understand that UCA is unable to rescind any disclosures already made with your permission, and that UCA is required to retain its records of the care provided to you.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

You have the following rights regarding medical information maintained about you:

• Right to Inspect and Copy. You have the right to inspect and receive a copy of medical information that may be used to make decisions about your care, unless your treating physician determines that providing you with such information would be injurious to your physical or mental well-being. When UCA denies your request to inspect and receive a copy of your medical information on this basis, you may request that the denial be reviewed. Another licensed health care professional chosen by UCA will review your request and the denial. The person conducting the review will not be the person who denied your request. UCA will do what this reviewer decides.

To inspect and receive a copy of your medical information, you must submit your request in writing to our office Privacy Officer. If you request a copy of the information, UCA may charge a fee for the costs of copying, mailing, or other supplies associated with your request and may collect the fee before providing the copy to you. If you agree, UCA may provide you with a summary of the information instead of providing you with access to it, or with an explanation of the information instead of a copy. Before providing you with such a summary or explanation, UCA first will obtain your agreement to pay the fees, if any, for preparing the summary or explanation.

• Right to Amend. If you believe that medical information we have about you is incorrect or incomplete, you may ask UCA to amend the information. To request an amendment, your request must be made in writing and submitted to the Privacy Officer. In addition, you must provide a reason that supports your request.

UCA may deny your request for an amendment:

• If it is not in writing;

• Does not include a reason to support the request;

• Was created by a provider other than UCA, unless the provider who created the information is no longer available to consider or make the amendment;

• Is not part of the medical information kept by or for UCA;

• Is not part of the information that you would be permitted to inspect and copy; or

• UCA has determined the information to be accurate and complete.

• Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we have made of medical information about you.

To request this list or accounting of disclosures, you must submit your request in writing to our Privacy Officer and state whether you want the list on paper or electronically. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, UCA may charge you for the costs of providing the list. UCA will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred. UCA may collect the fee before providing the list to you.

• Right to Request Restrictions. Except where UCA is required to disclose the information by law, you have the right to request a restriction or limitation on the medical information used or disclosed about you to individuals or entities outside of this office and on the use of psychotherapy notes within our office by someone other than the person who wrote the notes.

UCA is not required to agree to your request to restrict use or disclosure of your information within this office or among the health care professionals currently involved in your care at this office except with regard to psychotherapy notes. If UCA does agree, it will comply with your requested restriction unless the information is needed to provide you emergency treatment. Except as required or permitted by law, UCA will only disclose your confidential medical information to persons outside this office who are not currently involved in your care at the office, with and in accordance with your authorization.

To request restrictions, you must make your request in writing to UCA’s Privacy Officer. In your request, you must state: (1) what information you want to limit; (2) whether you want to limit its use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

• Right to Request How UCA Communicates with You. You have the right to request that UCA communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that UCA only contact you at work or by mail, or at a mailing address other than your home address.

To request certain types of communications, you must make your request in writing to the Privacy Officer and specify how or where you wish to be contacted. UCA will not ask you the reason for your request, and will accommodate all reasonable requests.

• Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice or any revised notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

CHANGES TO THIS NOTICE

UCA reserves the right to change this notice. UCA reserves the right to make the revised or changed notice effective for medical information already held about you as well as any information received in the future. UCA will post a copy of the current notice in the office. The notice will remain in effect for each subsequent visit unless changed. If the notice changes, a copy will be available to you upon request.

COMPLAINTS

If you have a complaint about your privacy rights, you may file a written complaint with this office or with the Secretary of the United States Department of Health and Human Services.

You will not be penalized for filing a complaint.