PAIN CONSULTANTS OF EAST TENNESSEE

NOTICE OF PRIVACY PRACTICES

Effective: September 1, 2013

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, our providers and staff will record information in your record that is related to your treatment.  This information is necessary for our providers to determine what treatment you should receive.  Our 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:

  • Evaluate the performance of our staff;
  • Assess the quality of care and outcomes in your case and similar cases;
  • Learn how to improve our services; or,
  • Determine how to continually improve the quality and effectiveness of the health care we provide.

 Appointments and Patient Recall Reminders. Pain Consultants of East Tennessee may use your information to provide appointment reminders 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:

  • For judicial and administrative proceedings pursuant to legal authority;
  • To report information related to victims of abuse, neglect or domestic violence; and,
  • To assist law enforcement officials in their law enforcement duties.

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:

  • Request a restriction on certain uses and disclosures of your information; however, Pain Consultants of East Tennessee is not required to agree to a requested restriction unless you specifically request that Pain Consultants of East Tennessee refrain from disclosing information to your health plan for services in which you have paid in full, out of pocket.
  • Obtain a paper copy of the Notice of Privacy Practices upon request;
  • Inspect and obtain a copy of your health record as permitted by law;
  • Obtain an electronic copy of your health information to the extent that it is maintained in an electronic medical record;
  • Request an amendment of your health record;
  • Request communications of your health information by alternative means or at alternative locations;
  • Receive an accounting of disclosures made of your health information; and,
  • Receive notification upon a breach of any of your unsecured health information.

Obligations of Pain Consultants of East Tennessee

 Pain Consultants of East Tennessee is required to:

  • Maintain the privacy of protected health information;
  • Provide you with this notice of its legal duties and privacy practices with respect to your health information;
  • Abide by the terms of this notice;
  • Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;
  • Accommodate reasonable request you may make to communicate health information by alternative means or at alternative locations; and
  • Obtain your written authorization to use of disclose your health information for reasons other than those listed above and/or permitted by law.

Complaints

You may complain to Pain Consultants of East Tennessee and 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 our waiting room.  You may request a copy of this Notice at any time.

 

Contact Information

If you have any questions or complaints, please contact:

Ms. Darla Sorah
1128 E. Weisgarber Road
Suite 100
Knoxville, TN  37909
865-934-2601

The undersigned acknowledges receipt of the Notice of Privacy Practices of Pain Consultants of East Tennessee on the dated noted below.

____________________________________
Signature of Patient or Legal Representative

 

_____________________________
Printed Name

 

______________________________
Date

 


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