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.
Physician’s Surrogacy and its affiliated entities use health information about you for treatment, to obtain payment for treatment, to evaluate the quality of care you receive, and for other administrative and operational purposes. Your health information is contained in a medical record that is the physical property and responsibility of Physician’s Surrogacy. Physician’s Surrogacy is required by law to maintain the privacy of health information about you and provide you with this notice of our legal duties and privacy practices with respect to your health information (“Notice of Privacy Practices” or “Notice”). We must abide by the terms of this Notice currently in effect. Physician’s Surrogacy reserves the right to change the terms of this Notice, our privacy practices, and to make the new provisions effective for all protected health information we maintain. You may contact us at the address or phone listed below to obtain a revised notice of privacy practices.
Your Health Information Rights: You have the following rights with respect to health information about you.
Right to Copy of Notice of Privacy Practices. You have the right to a paper copy of our Notice at any time. Please contact us at the address or phone listed below to obtain a copy.
Right to Inspect and Copy. You have the right to inspect and/or obtain a copy of the health information about you that we maintain. Your request must be in writing. We will charge you a fee to cover the costs of copying and mailing that are necessary to fulfill your request. In very limited circumstances, we may deny your request. If we deny your request, we will explain our reasons in writing. Under certain circumstances, you have the right to request that another person at Physician’s Surrogacy review the decision. We will comply with the review outcome.
Right to Amend. If you feel that health information about you that we maintain is inaccurate or incomplete, you have the right to request that we amend the information. You may request an amendment as long as we maintain the information. We may ask that you submit it in writing and include a reason supporting the request. In certain circumstances, we may deny your request. If your request is denied, we will explain our reasons in writing. You may submit a statement explaining why you disagree with our decision to deny your amendment request. We will share your statement when we disclose health information about you that we maintain in certain groups of records.
Right to an Accounting of Disclosures. You have the right to request an accounting or detailed listing of certain disclosures of health information about you. The time period covered by the accounting is limited to six years prior to the date of your request. Your request must be in writing. If you request an accounting more often than once every twelve (12) months, we may charge you a fee to cover the costs of preparing the accounting.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information about you that we use or disclose. Your request must be in writing. We are not required to agree to your request. However, we must agree not to disclose health information about you to your health plan if the disclosure is for payment or health care operations and relates to a health care item or service which you paid for in full out of pocket. If we agree to your request, we will comply with it unless the information is needed for emergency treatment. We will notify you if we are unable to agree to a requested restriction.
Right to Revoke Authorization. You have the right to revoke your authorization to use or disclose health information, except to the extent that action has been taken in reliance upon your authorization. Your request must be in writing
Right to Request Alternative Method of Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Your request must be in writing. We will accommodate all reasonable requests.
Right to Notification of Breach. You have a right to be notified if you are affected by a breach of unsecured health information about you.
Right to Opt Out of Fundraising Communications. We may contact you for fundraising purposes. You have the right to opt out to receiving these communications.
Complaints: If you believe your privacy rights have been violated, you may complain to Physician’s Surrogacy and to the Secretary of the Department of Health and Human Services. You may make a complaint to us by contacting Physician’s Surrogacy’s Chief Medical Officer at the address or phone listed on this website. You will not be retaliated against for filing a complaint.
Uses or Disclosures of Your Health Information That May Be Made Without Your Authorization
Treatment. We may use and disclose health information about you to provide you with pharmacy care or other medical treatment or services. For example, information related to your treatment may be communicated with and obtained by a health care provider, such as a pharmacist, nurse, or other person providing health services to you, and will be recorded in your medical record. This information is necessary for health care providers to determine what treatment you should receive.
Payment. We may disclose health information about you for payment related purposes. For example we may contact your insurer, payor, or other entity, for purposes of receiving payment for treatment and services that you receive or to determine whether the entity will pay for the particular product or service. The billing information may identify you, your diagnosis, and treatment or supplies used in the course of your treatment.
Health Care Operations. We may use and disclose health information about you for administrative and operational purposes. For example, members of the risk management or quality improvement teams may use health information about you to assess the care and outcomes in your case and others like it. The results will be used internally to continually improve the quality of care for all patients.
Organized Health Care Arrangement. An organized health care arrangement is a clinically integrated care setting in which individuals typically receive health care from more than one health care provider. We may participate in organized health care arrangements with long-term care facilities, hospice, or other health care facilities in connection with the services we furnish to patients in such settings. Health information may be shared between the participants in the organized health care arrangement for the health care operations of the arrangement.
Individuals Involved in Your Care or Payment for Your Care. We may disclose to a family member, other relative, close personal friend or any other person you identify, health information about you directly relevant to that person’s involvement in your care or payment related to your care. In addition, we may disclose health information about you to a public or private entity assisting in a disaster relief effort (such as the Red Cross) so that your family can be notified about your condition, status, and location
Business Associates. We provide some services through contracts with business associates, such as accountants, consultants, and attorneys so that they can perform the tasks that we have assigned to them. To protect your health information, we require the business associate to appropriately safeguard health information about you.
Appointment Reminders. We may use health information about you to provide you with appointment or prescription reminders.
Alternative Treatments. We may use health information about you to provide you with information about alternative treatments or other health-related benefits and services that may be of interest to you.
Future Communications. We may communicate with you via newsletters, mailings, or other means regarding treatment options, health-related information, disease-management programs, wellness programs, or other community-based initiatives or activities in which we are participating.
Required by Law. We may use and disclose health information about you as required by federal, state, or local law. For example, we may disclose health information for the following purposes: (1) for judicial or administrative proceedings pursuant to legal authority; (2) to report information related to victims of abuse, neglect, or domestic violence; and (3) to assist law enforcement officials in their law enforcement duties.
Public Health. We may use or 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.
Health Care Oversight. We may use or disclose health information about you to a health oversight agency for oversight activities authorized by law, such as audits, investigations, and inspections.
Research. We may use or disclose health information about you to reserachers if an institutional review board or privacy board has reviewed and approved the research proposal, and established protocols to ensure the privacy of your health information.
Health and Safety. We may use or disclose health information about you to avert a serious threat to your health or safety or any other person pursuant to applicable law.
Medical Examiners and Others. We may use or disclose health information about you to medical examiners, coroners, or funeral directors to allow them to perform their lawful duties. If you are an organ or tissue donor, we may disclose health information about you to organizations that help with organ, eye, and tissue donation and transplantation.
Food and Drug Administration (FDA). We may use or disclose health information for purposes of notifying the FDA of adverse events with respect to food, supplements, product, and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacements.
Information Not Personally Identifiable. We may use or disclose health information about you in ways that do not personally identify you or reveal who you are.
Government Functions. We may use or disclose health information about you for specialized government functions, such as protection of public officials, national security and intelligence activities, or reporting to various branches of the armed services.
Workers Compensation. We may use or disclose health information about you to comply with laws and regulations related to workers compensation.
Correctional Institutions. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may use or disclosure health information about you. Such health information will be disclosed to the correctional institution or law enforcement official when necessary for the institution to provide you with health care and to protect the health and safety of others.
Affiliated Covered Entity. We are part of an affiliated covered entity with other entities that are under common ownership or control. The entity treats itself as a single entity for purposes of using and disclosing health information about you.
Uses or Disclosures of Your Health Information Based Upon Your Written Authorization
Psychotherapy Notes. We must obtain your written authorization for must uses and disclosures of psychotherapy notes.
Marketing. We must obtain your written authorization to use and disclose health information about you for most marketing purposes.
Sale of Your Health Information. We must obtain your written authorization for any disclosure of health information about you which constitutes a sale of such health information.
Other Uses. Other uses and disclosures of health information about you, not described above, will be made only with your written authorization. You may revoke your authorization, at any time, in writing, except to the extent that we have taken action in reliance on the authorization.
Other Applicable Laws
This Notice is provided to you as a requirement of the Health Insurance Portability and Accountability Act (“HIPAA”). There are other laws that may apply and limit our ability to use and disclose health information about you beyond what we are allowed to do under HIPAA.
State Laws. We will comply with your state’s laws if they provide you with greater rights over your health information or provide for more restrictions on the use or disclosure of your health information.
Contact Information: If you have any questions, requests, or concerns about your Physician’s Surrogacy-related health information rights or our use and disclosure of health information, please contact us at the address and contact numbers listed on our website.
Updated Effective March 9, 2023