Notice of Privacy Practices
Effective Date: 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.
Permitted Uses and Disclosures of Medical Information
To the extent provided by law, Tri-County Medical Associates (“Tri-County”) is permitted to use or disclose your identifiable medical information for treatment (such as, sending your medical information to a specialist physician as part of a referral), to obtain payment for your treatment (such as, sending billing information to your health insurance plan) and for Tri-County’s health care operations (such as, to evaluate the quality of care that you receive by comparing your medical information with other patient data).
Tri-County may also contact you to provide appointment reminders, information about treatment alternatives or health-related benefits and services that may of interest to you. In addition, in its role as a group health plan, Tri-County may contact its employees for fundraising purposes and may use or disclose medical information of its employees to the sponsor of Tri-County’s group health plan.
Tri-County is also permitted to use or disclose your medical information without your authorization for the following purposes:
Required by Law. To the extent Tri-County is required to do so by applicable federal or state law.
Public Health Activities. To public health authorities for the following purposes: to prevent or control disease, injury or disability; to report births and deaths; for public health surveillance, investigations and interventions; to report child abuse or neglect; to the Food and Drug Administration (FDA) for the purpose of supporting activities related to quality, safety or effectiveness of FDA-regulated products or activities; to notify people who may have been exposed to certain communicable diseases; and, in certain circumstances, to communicate with your employer in connection with work-related illness, injury or medical surveillance.
Abuse. To inform governmental authorities and protective service agencies about patients whom Tri-County reasonably believes are victims of abuse, neglect or domestic violence.
Health Oversight Activities. To health oversight agencies authorized by law to audit, inspect, investigate, license, discipline or other activities necessary to oversee the health care system, government benefit programs, government regulatory programs for which health information is necessary for determining compliance with program standards, and other entities subject to civil rights laws for which health information is necessary for determining compliance.
Legal Proceedings. In the course of legal proceedings in response to a valid court order and, under certain circumstances, in response to a subpoena or discovery request.
Law Enforcement. To a law enforcement agency if, for example, Tri-County receives a subpoena, summons or warrant for the information in connection with a criminal proceeding or investigation, to identify or locate a suspect, fugitive or missing person or in emergency circumstances to report a crime.
Decedents. To funeral directors, coroners, or medical examiners.
Organ and Tissue Donation. To organ donor organizations for the purpose of facilitating organ, eye or tissue donation and transplantation.
Research. For research purposes, provided that, the research has been approved by an institutional review board or privacy board to ensure that the researchers will follow procedures to safeguard the privacy of the medical information.
Threats to Health or Safety. Consistent with applicable law and standards of ethical conduct, if Tri-County in good faith believes the use or disclosure is necessary to prevent or lessen a serious threat to the health or safety of you or the public.
Military, National Security and Correctional Institutions. With regard to medical information of individuals who are Armed Forces or foreign military personnel, as required by such applicable military authorities; to federal officials for intelligence, counterintelligence and national security activities, including protective services for the President and other federal officials; and, with regard to medical information of an inmate or other individual, to a correctional institution necessary in lawful custody of such inmate or individual, if necessary for the health and safety of such individuals.
Workers’ Compensation. For workers’ compensation or similar programs that provide benefits for work-related injuries or illness.
Uses and Disclosures Requiring an Opportunity to Object
Individuals Involved in Your Care and for Notification Purposes. Unless you object (or circumstances, such as, incapacity or emergency, make objection impracticable), Tri-County may disclose to your family member, relative, close personal friend or other person you identify, medical information that is directly relevant to that person’s involvement in your care or payment related to your care, or, to the extent applicable, to assist in notifying that person of your location (e.g., if you became hospitalized) and general condition. To the extent applicable, in the case of a disaster, Tri-County may inform disaster relief agencies of your location and general condition.
Other Uses and Disclosures Requiring Authorization
In any other situation, Tri-County will ask for your written authorization before using or disclosing any medical information about you. These situations include, but are not limited to, use or disclosure of specific medical information (such as, psychotherapy notes unrelated to treatment, payment or health care operations) and certain marketing activities. If you choose to sign an authorization to disclose information, you can later revoke that authorization at any time. In such circumstances, Tri-County will ask for you to provide a revocation in writing to stop any future uses and disclosures.
Your Individual Rights
Right to Request Restrictions. You have the right to request a restriction on the medical information Tri-County uses or discloses about you for treatment, payment or health care operations. You also have the right to request a restriction on the medical information Tri-County discloses about you to someone (such as, a family member or friend) who is involved in your care or payment for your care. However, Tri-County is not required to agree to your request.
Right to Receive Confidential Communications. You have the right to request that your medical information be communicated to you in a confidential manner, such as, sending mail to an address other than your home. To make such a request, you must do so in writing and supply Tri-County with an alternative address or method of contact. Tri-County will accommodate all reasonable requests.
Right to Inspect and Copy. You have the right to inspect and copy your medical information for as long as Tri-County maintains it. However, you may not inspect or copy the following kinds of records: psychotherapy notes, medical information compiled in reasonable anticipation of or use in a legal proceeding and medical information that is subject to any law that prohibits your access.
Right to Amend. You have the right to request that Tri-County amend your medical information for as long as Tri-County maintains it, if you believe your medical information is incorrect or incomplete. To request such an amendment, you must submit your request to Tri-County in writing with a reason supporting your request. Tri-County may deny your request, however, if applicable law requires or permits Tri-County to deny it or if Tri-County determines your medical information is correct and complete.
Right to an Accounting of Disclosures. You have the right to request an accounting of instances in which Tri-County has disclosed your medical information to others. This right is limited to disclosures made by Tri-County after the effective date of this notice and does not include (a) disclosures made by Tri-County for the purpose of your treatment, payment or health care operations; or (b) disclosures made by Tri-County pursuant to your written authorization.
Right to a Paper Copy of Notice. You have the right to obtain a paper copy of this notice, even if you agreed to receive it electronically, upon request to Tri-County at any time.
Our Legal Duty
Tri-County is required by law to protect the privacy of your medical information and to provide this notice to you about Tri-County’s legal duties and privacy practices with respect to your medical information. Tri-County is required to abide by terms described in this notice. Tri-County reserves the right to change the terms of this notice and to make the new notice terms effective for all medical information it maintains about you. Upon request, Tri-County will provide you with a copy of the most up-to-date version of this notice. In addition, Tri-County will post any revised version of this notice in patient waiting areas, examination rooms and, when it becomes available, on Tri-County’s web site.
If you believe that your privacy rights have been violated or you disagree with a decision Tri-County has made about access to your medical information, you may contact the person listed below. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request. Under no circumstance will you be retaliated against for filing a complaint.
For more information about Tri-County’s privacy practices, or if you have any questions or complaints, please contact Tri-County’s Privacy Officer, Martha Lingard, at the following address:
Operations Manager and Privacy Officer
Tri-County Medical Associates, Inc.
9 Industrial Road, Suite #5
Milford, MA 01757