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PAIN CONSULTANTS OF EAST TENNESSEENOTICE OF PRIVACY PRACTICESEffective: 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. Pain Consultants of East Tennessee uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of Pain Consultants of East Tennessee. How Pain Consultants of East Tennessee May Use or Disclose Your Health Information For Treatment. Pain Consultants of East Tennessee may use your health information to provide you with medical treatment or services. For example, health care providers, such as physicians, nurses, or other persons providing health services to you, will record information in your record that is related to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions taken by them in the course of your treatment and note how your respond to the actions. For Payment. Pain Consultants of East Tennessee may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, we may send a bill to you or a third-party payor, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment. For Health Care Operations. Pain Consultants of East Tennessee may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to members of our staff and others to:
Appointments and Patient Recall Reminders. Pain Consultants of East Tennessee may use your information to provide appointment reminders, reminders that you are due for periodic care, or information about treatment alternatives or other health related benefits and services that may be of interest to you. We may contact you by telephone, in writing, email, or otherwise and may involve leaving a message which could potentially be picked up by others. Others Involved in Your Care. We may disclose information about you to others who may be involved in your medical care. Unless you clearly instruct us to the contrary, we may disclose information to a friend or family member who is involved in your medical care. Required By Law. Pain Consultants of East Tennessee may use and disclose information about you as required by law. For example, Pain Consultants of East Tennessee may disclose information for the following purposes:
Written Authorization. Other uses or disclosures not covered by this Notice or the applicable laws may be made with your specific written permission. You may revoke your written permission at any time and we will immediately cease such uses or disclosures. You understand that we cannot take back any disclosures already made prior to your revocation. Public Health. Pain Consultants of East Tennessee may use and disclose your health information 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. Decedents. Pain Consultants of East Tennessee may use and disclose your health information to funeral directors, medical examiners, or coroners to enable them to carry out their lawful duties. Organ/Tissue Donation. If you are an organ donor, Pain Consultants of East Tennessee may use and disclose your health information for cadaveric organ, eye or tissue donation purposes. Research. Pain Consultants of East Tennessee may use and disclose your information for research purposes when the research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. Health and Safety. Pain Consultants of East Tennessee may use and disclose your health information to avert a serious threat to the health or safety of you or any other person pursuant to applicable law. Government Functions. Pain Consultants of East Tennessee may use and disclose your information for specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your information. Workers Compensation. Your health information may be used and disclosed to comply with laws and regulations related to Workers Compensation. Inmates. If you are an inmate or under custody of a law enforcement official, we may release information about you to the correctional institution or law enforcement official: (1) for the institution to provide you with healthcare; (2) to protect your health and safety or that of others; or, (3) for the safety and security of the correctional institution. Your Health Information Rights You have the right to:
Contact the Privacy Official at Pain Consultants of East Tennessee for more information on how to exercise your rights. Obligations of Pain Consultants of East Tennessee Pain Consultants of East Tennessee is required to:
Complaints You may complain to Pain Consultants of East Tennessee and/or to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint. To file a complaint with Pain Consultants of East Tennessee, contact our Privacy Official. All complaints must be in writing. Changes to this Notice We reserve the right to change this Notice at any time and to make the revised Notice effective for health information we already have about you. We will post a copy of the current Notice in the lobby. You may request a copy of this Notice at any time. Contact Information If you have any questions or complaints, please contact: Darla Sorah Privacy Official 220 Fort Sanders West Boulevard Suite 308 Knoxville, TN 37920 865-579-0552 The undersigned acknowledges receipt of the Notice of Privacy Practices of Pain Consultants of East Tennessee on the dated noted below. ______________________________ Signature ______________________________ Printed Name ______________________________ Date |