Download Privacy Forms
(PDF Format)

Release of info to OBGYN

Release of info from OBGYN


NOTICE OF PRIVACY PRACTICES

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

This notice is being published in response to a 1996 Congressional measure called Health Information Privacy and Accountability Act (HIPAA). Dubuque Obstetrics & Gynecology, P.C. has and continues to respect patient confidentiality. HIPAA has outlined new standards and this handout addresses our current office procedures in relation to the regulations.

Provision of Notice: Dubuque Obstetrics & Gynecology, P.C. provides a Notice of Privacy Practices to every patient with whom it has a direct treatment relationship. The Notice is provided on the first date in our office after April 13, 2003 or at any time upon request. The notice is also posted on our web site: www.dbqobgyn.com.

Documentation of Provision of Notice: When a direct treatment patient receives the Notice, we ask the patient to acknowledge receipt by signing an adhesive form to be filed in the patient medical record. If the patient refuses to sign the form, the refusal is noted on the label and placed in the patient medical record.

Effective Date and Changes to Notice: This Notice is effective April 14, 2003. The practice reserves the right to revise this Notice at any time. Updated copies will be available at your request in our office and posted on our web site: www.dbqobgyn.com.

Complaints: Dubuque Obstetrics & Gynecology, P.C. allows all patients and their agents to file complaints with the practice and with the Secretary of the Department of Health and Human Services (DHHS) whenever he or she believes that the practice has violated their rights. Complaints to the practice must be in writing, must describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time the patient became aware or should have become aware of the violation. Complaints must be addressed to the attention of the Privacy Officer at Dubuque Obstetrics & Gynecology, P.C. The practice investigates each complaint and may, at its discretion, reply to the patient or the patient's agent. The practice does not take any adverse action against any patient who files a complaint against the practice.

Contact Person: The practice has a Privacy Officer that serves as the contact person for all issues related to the Privacy Rule. The Privacy Officer is the Office Manager. If you have any questions about this Notice, please contact: Dubuque Obstetrics & Gynecology, P.C. Attn: Privacy Officer 1500 Delhi Street, Ste 3100 Dubuque, Iowa 52001-6319

USES AND DISCLOSURES OF PROTECTED INFORMATION

Uses and Disclosures - Treatment, Payment, and Healthcare Operations Dubuque Obstetrics & Gynecology, P.C. uses and discloses protected health information (PHI) for payment, treatment, and healthcare operations.

  • Treatment includes activities related to providing and coordinating services to the patient. Examples include discussing care plans with medical / midwifery students, pharmacists and hospitals.
  • Payment relates to all activities associated with getting reimbursed for services provided, including submission of claims to insurance companies and any additional information requested by the insurance company so they can determine if they should pay the claim. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also we may use your PHI to bill you directly for services and items.
  • Healthcare operations support our daily operations as a quality healthcare provider. Examples include utilizing your PHI to evaluate the quality of care you received from us.

Uses and Disclosures - Not Requiring Authorization Dubuque Obstetrics & Gynecology may use PHI without your authorization in the following circumstances:

  • Disclosure to those involved in an individual's care is allowed when the patient approves or, when the patient is not present or not able to approve, when such disclosure is deemed appropriate in the professional judgment of the practice;
  • Use and disclosure for courtesy appointment reminders;
  • Uses and disclosures required by law include disclosing protected health information to public health officials. Examples of this include reporting of communicable diseases (i.e. sexually transmitted diseases), medical conditions or procedures including miscarriages. We are also required to report suspected abuse or neglect;
  • For health oversight activities: involves information used and released for audits, investigations, licensure issues, and other health oversight activities;
  • For judicial and administrative proceedings;
  • For law enforcement purposes;
  • Related to deceased individuals, such as PHI required for identification by a coroner or medical examiner and funeral directors as required by law. The attending physician is required to sign the death certificate and provide the coroner with a copy of the decedent's protected health information.
  • Related to cadaveric organ, eye or tissue donations;
  • Uses and disclosures to avert a serious threat to health or safety;
  • Uses and disclosures for specialized government functions;
  • Uses and Disclosures in Emergency Situations: The practice uses and discloses protected health information as appropriate to provide treatment in emergency situations.

Uses and Disclosures - Do Not Apply to Practice

  • Research: The practice does not engage in any research activities that require it to use or disclose protected health information.
  • Other Uses and Disclosures: The practice does not use or disclose protected health information to an employer or health plan sponsor, for underwriting and related purposes, to brokers and agents unless authorized by the patient.

INDIVIDUAL RIGHTS

Individual Rights - Accounting for Disclosures of Protected Health Information The practice tracks disclosures of a patient's protected health information. Disclosures not tracked include: treatment, payment, healthcare operations, disclosures made to the patient or a person involved in the patient's care, disclosures as a result of a patient authorization, disclosures for national security or intelligence purposes, to correctional institutions and to law enforcement officials. A form to request an accounting of disclosures can be received by contacting the Privacy Officer.

Individual Rights - Inspect and Copy Protected Health Information The practice allows individuals to inspect and copy their protected health information and charges a reasonable fee for the inspection of and copying of records. A form to request an inspection or copy can be made by contacting the Privacy Officer.

Individual Rights - Request Amendment to Protected Health Information The practice allows an individual to request that the practice amend the protected health information maintained in the patient's medical record or the patient's billing record. The requests must be in writing and should be marked "Attention: Privacy Officer."

Individual Rights - Request Confidential Communications The practice accommodates all reasonable requests to keep communications confidential. The practice determines the reasonableness based on the administrative difficulty of complying with the request. A request for confidential communications must be in writing, must specify an alternative address or other method of contact, and must provide information about how payment will be handled. The request must be addressed to the practice's Privacy Officer. No reason for the request needs to be stated. The practice accommodates all reasonable requests.

Individual Rights - Request Restriction of Disclosures The practice accepts requests for restrictions of disclosures of protected health information. All requests for restrictions of disclosures must be submitted in writing and sent to the attention of the practice's Privacy Officer. The Privacy Officer notifies the requestor in writing of the practice's response to the request.

Individual Rights - Authorizations The practice obtains a written authorization from a patient or the patient's representative for the use or disclosure of protected health information for other than treatment provided by or recommended by our providers, payment, or healthcare operations. In Iowa, a specific written authorization is required to disclose or release mental health, substance abuse (alcohol and drug) or HIV/AIDS information.

An individual may revoke an authorization at any time. The revocation must be in writing and must be sent to the attention of Privacy Officer; however, the practice may have already disclosed or used the information prior to revocation.

Individual Rights - Waiver of Rights The practice never requires an individual to waive any of his or her individual rights as a condition for the provision of treatment, except under very limited circumstances allowed under law.