Effective 4/14/2003
Health Insurance Portability and Accountability Act
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.
If you have any questions, please contact our Privacy Office at the address or phone number at the bottom of this notice.
Who will follow this notice?
Bernardo D. Martinez, M.D., F.A.C.S., Inc. provides health care to patients, residents, and clients in partnership with physicians and other professionals and organizations. The information privacy practices in this notice will be followed by:
- Any health care professional who treats you at our location.
- All departments, units and affiliated entities of our organization.
- All employed and non-employed by Bernardo D. Martinez, M.D., F.A.C.S., Inc associates, contractors, students in training, volunteers of our organization.
- Any business associate or partner of Bernardo D. Martinez, M.D., F.A.C.S., Inc with whom we share health information.
Our pledge to you
We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care that we maintain, whether created by office staff or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your medical information created in the doctor's office. We are required by law to:
- keep medical information about you private.
- give you this notice of our legal duties and privacy practices with respect to medical information about you.
- follow the terms of the notice that is currently in effect.
Changes to this Notice
We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. Before we make a significant change in our policies, we will change our notice and post the new one within the facility and on our Web site at http://www.ohioroboticsurgery. com. We will provide you a revised notice during your first visit after the revisions are effective. You may request a copy of the current notice at any time. The effective date is listed just below the title. You will also be asked to acknowledge in writing your receipt of this notice.
How we may use and disclose medical information about you
- We may use and disclose medical information about you for treatment (such as sending medical information about you to a specialist or family doctor as part of a referral); to obtain payment for treatment (such as sending billing information to your insurance company or Medicare); and to support our health care operations (such as comparing patient data to improve treatment methods.)
- We may use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give out medical information about you without prior authorization for public health purposes, birth, death, abuse, neglect or domestic violence reporting, health oversight audits or inspections, qualified research studies, funeral arrangements and organ donation, workers' compensation purposes to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and other emergencies. We also disclose medical information when required by law, such as in response to a request from law enforcement , certain independent review organizations, or the coroner's office in specific circumstances, or in response to valid judicial or administrative orders.
- We also may contact you for appointment reminders, follow up calls after treatment, satisfaction surveys to you or your family members , to tell you about or recommend possible treatment options, alternatives, health-related benefits or services that may be of interest to you.
- We may disclose medical information about you to a friend or family member who is involved in your medical care or to disaster relief authorities so that your family can be notified of your location and condition.
Other uses of medical information
- In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing medical information about you. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision.
Your rights regarding medical information about you
- In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care, when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing or other related supplies. We must, however, provide a free copy of your medical information to the Bureau of Workers' Compensation, the Industrial Commission, the Department of Jobs and Family Services, or to you or your representative if the purpose of the request is to support a claim under the Social Security Act and if your request is accompanied by documentation to support such a claim. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.
If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct our records, by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend a record if the information was not created by us, if it is not part of the medical information maintained by us or if we determine that record is accurate. You may appeal, in writing, a decision by us not to amend a record.
- You have the right to a list of those instances where we have disclosed medical information about you , other than for treatment, payment, health care operations or where you specifically authorized a disclosure, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003 . You will receive the list in paper form. The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before you incur any costs.
- If this notice was sent to you electronically, you have the right to a paper copy of this notice.
- You have the right to request that medical information about you be communicated to you in a confidential manner , such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use to communicate with you.
- You may request, in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request but we are not legally required to accept it. We will inform you of our decision on your request.
All written requests or appeals should be submitted to our Privacy Office listed at the end of this notice.
Complaints
- If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Office (listed below).
- Finally, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Privacy Office can provide you the address.
- Under no circumstances will you be penalized or retaliated against for filing a complaint.
BERNARDO D. MARTINEZ , M.D., F.A.C.S., INC.
Privacy Officer contact information
Privacy Officer
2213 Cherry St. ACC Suite 305
Toledo , OH 43608
419-251-2560 |
