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Effective Date: April 14, 2003

We are required by law to: 

v       Give you notice of our legal duties and privacy practices with respect to medical information about you

v       Follow the terms of the notice that is currently in effect

v       Maintain the privacy of your health information as required by law

v       Notify you if we cannot accommodate a requested restriction or request

v       Accommodate your reasonable requests regarding methods to communicate health information with you

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain.  If our information practices change, we will amend our Notice.  You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our Notice or by visiting our office and picking up a copy.

How we may use and disclose medical information about you:

The following describes the different ways that we use and disclose medical information.  For each category of uses or disclosures, we will explain what we mean and try to give some examples.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

TREATMENT:  We may use medical information about you to provide you with medical treatment or services.  We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are taking care of you.  For example:

 v       Your physician or a staff member may need to talk to another physician who will provide care when he or she is away.

v       During the course of your treatment, the physician determines he will need to consult with another specialist in the area.  He will share the information with such specialist and obtain his/her input.

v       A nurse/medical staff obtains treatment information about you and records it in a health record. 

PAYMENT:  We may use and disclose medical information about you so that the treatment and services you receive from Dr. NeeOo W. Chin M.D. may be billed to and collected from you, an insurance company, or a third party.  We may tell an insurance company or a third party about care you are going to receive in order to obtain prior approval or determine your coverage. For example: 

v       Letter of medical necessity to insurance company for prior authorization for treatment.

HEALTH CARE OPERATIONS:  In order to run our practice in a way that ensures that our patients receive quality care, we may use and disclose medical information for health care operations. For example:

 v       Use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.

v       Disclose medical information to nurses, technicians, medical assistants, and/or insurance staff for review and learning purposes.

MARKETING:  We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you.

NOTIFICATION:  Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member or other person responsible for your care about your location and your general condition or for payment purposes. 

v       We may release medical information about you to a spouse/partner who is involved in your medical care.

v       We may tell a family member, other relative, or any other person you identify, your condition and that you are receiving care, if you do not object or in an emergency.

v       We may release information about treatment you received to a family member or other person responsible for payment for such care. 

RESEARCH:  We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.  If you are a candidate for participation in a research project, you will always be given very specific information about the research project and be asked if you want to participate.  If it is necessary to disclose your name or address or other information that specifically reveals who you are, we will ask specific permission from you for that.  Examples include: 

v       Researchers may need to look for patients with specific medical needs and we may assist them with that.

v       Your physician may decide to participate in a research project testing the effects of a new medication. 

AS REQUIRED BY LAW:  We will disclose medical information about you when we are required to do so by federal, state, or local law. For example: 

v       We are required to report suspected child or elder abuse or neglect.

v       As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury or disability. (i.e., to report HIV or other STD, or tuberculosis, etc.). 

PUBLIC HEALTH RISKS:  We may disclose medical information about you for public health activities.  These include the following: 

v       To prevent or control disease, injury or disability

v       To report reactions to medications or problems with medical products.

v       To notify people of recalls of products they may be using.

v       To notify a person who may have been exposed to a disease or may be at risk for contacting or spreading a disease or condition. 

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY:  We may use and disclose medical information about you when it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or of another person.  Any disclosure will be to someone who is able to help prevent the threat.

WORKERS’ COMPENSATION:  If you are seeking compensation through Workers’ Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers’ Compensation.

FOOD AND DRUG ADMINISTRATION:  We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

DISASTER RELIEF:  We may use and disclose your protected health information to assist in disaster relief efforts.

CORONERS, MEDICAL EXAMINERS, AND FUNERAL DIRECTIVES:  We may release medical information to a coroner or medical examiner.  This may be necessary for example, to identify a deceased person or determine the causes of death.  We may also release medical information about patients to funeral directors as necessary to carry out their duties.

HEALTH OVERSIGHT ACTIVITIES:  We may disclose 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.

LAW ENFORCEMENT:  We may release medical information if asked to do so by a law enforcement official:

v       In response to a court order, subpoena, warrant, summons, or similar process

v       To identify or locate a suspect, fugitive, material witness, or missing person

v       About the victim of a crime if, under certain circumstances, we are unable to obtain the victim/patient’s agreement

v       About a death we believe may be the result of criminal conduct

v       About criminal conduct in the practice’s office

v       In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

INMATES:  If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.

LAWSUITS AND DISPUTES:  If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order.  We may also disclose medical 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.

NATIONAL SECURITY PURPOSES:  We may disclose your protected health information for specialized government functions as authorized by law as needed for national security purposes.

OTHER USES:  All other uses and disclosures must be made pursuant to your written authorization.  You may revoke authorizations by delivering a written revocation notice to our office.  You understand that we are unable to take back any disclosure we have already made with your permission, and that we are required to retain our records of the care that we provided you.

If we maintain a website that provides information about our practice, this Notice will be on the website.

Your rights regarding medical information about you:

The health and billing records we maintain are the physical property of the doctor’s office.  The information in it, however, belongs to you.  You have a right to: 

v       Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office.  We are not required to grant the request but will comply with any request granted unless the information is needed to provide you emergency treatment.  To request restrictions, you must make your request in writing to the address below.  In your request, you must tell us 1) What information you want to limit, 2) Whether you want to limit our use, disclosure, or both, and 3) to whom you want the limits to apply, for example, disclosures to your spouse.

v       Request that you be allowed to inspect and copy your health record and billing record.  You may exercise this right by delivering the request in writing to our office.   To inspect and copy your medical information, you must submit your request to:

The office of NeeOo W. Chin, M.D.

Attn:  Melinda

2814 Mack Road

Fairfield, OH  45014

Dr. Chin may deny your request to inspect and copy your medical information in certain very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed health care professional will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will comply with the outcome to the review. 

v       Request that your health care record be amended.  If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for this practice.  To request an amendment, your request must be made in writing and submitted to the above address.  Your request should include the reason that supports your request. 

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny your request if you ask us to amend information that: 

v       Was not created by NeeOo W. Chin, Inc., unless the person or entity that created the information is no longer available to make the amendment.

v       Is not part of the medical information kept by or for NeeOo W. Chin, Inc.

v       Is not part of the information which you would be permitted to inspect and copy.

v       Is accurate and complete. 

v       Request an “accounting of disclosures”.   This is a list of the disclosures we made of medical information about you.  An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request.  To request this list or accounting of disclosures, you must submit your request in writing to the above address.  Your request must state a time period and may not be longer than six years.  Dates before January 1, 2003 may not be available.  The first list you request within a 12-month period will be free of charge.  For additional lists, we may charge you for the costs of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request at the time before any costs are incurred.

v       Request Confidential Communications.  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or only by mail.  This request must be made in writing.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  Your request must be specific of how or where you wish to be contacted and must include phone numbers and/or addresses when applicable.

v       Request a Paper Copy of This Notice.  You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time.  To obtain a paper copy of this notice, submit your request in writing to: 

The office of NeeOo W. Chin, M.D.

Attn:  Melinda

2814 Mack Road

Fairfield, OH  45014

CHANGES TO THIS NOTICE

We reserve the right to change this notice.  We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future.  We will post a copy of the current notice in the waiting room.  The notice will contain the effective date in the upper right corner of the first page.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services.  To file a complaint with the practice, contact C.L. Creech, Privacy Official, (513) 326-4300.  All complaints should be submitted in writing. 

You will not be penalized, discriminated against, retaliated against, or intimidated for filing a complaint.

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