Burlington Family Practice respects your privacy and understands that your personal health information is very sensitive. We respect our legal obligation to keep health information that identifies you as private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.

Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes, which you do when signing the billing encounter slip at the time of your visit.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations

For treatment:

• Information obtained by a nurse, physician, or other member of our health care team will be recorded in your medical record and used to help decide what care may be right for you.
• We may also provide information to others providing you care. This will help them stay informed of your care.
• We may fax your requested medication refill to your pharmacy.

For payment:

• Health plans may require information from us about your medical care to determine benefits, pre-existing conditions and any appeals. Information provided to health care plans may include your diagnosis, procedures performed, or recommended care.

For health care operations:

• We use your medical records to assess quality and improve services.
• We may use and disclose medical records to review the qualifications of our health care providers.
• We may use and disclose your information to conduct or arrange for services, including: medical quality review by your health plan; accounting, legal, risk management, and insurance services; audit functions, including fraud and abuse detection and compliance programs.

Your Health Information Rights:

The health and billing records we create and store are the property of Burlington Family Practice. The protected health information in it, however generally belongs to you. You have the right to:

• Receive, read, and ask questions about this Notice;
• Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. We are not required to agree to do this, but if we agree, we must honor the restrictions you want.
• Request and receive from us a copy of the most current Notice of Privacy Practices for Protected Health Information (“Notice”);
• Ask to see or to get photocopies of your health information. A request must be in writing. You need to allow up to 30 days for us to process your request and may have to pay for photocopies in advance.
• Ask us to amend your health information if you think it is incorrect or incomplete. You may give us this request in writing and if we agree, we will amend the information within 60 days of request. You may write a statement of disagreement if your request is denied. It will be stored in your medical record, and included in any release of your record.
• When we receive a written request, we will give you a list of disclosures of your health information. By law, the list will not include; disclosures for purposes of treatment, payment or health care options and where required by law. You are entitled to one list per year without charge.
• Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released.

We may use and disclose your protected health information without your authorization as follows:

• With Medical Researchers-if the research has been approved and has policies to protect the privacy of your health information. We may also share information to medical researchers preparing to conduct a research project.
• To Funeral Directors/Coroners consistent with applicable law to allow them to carry out their duties.
• To Organ Procurement Organizations (tissue donation and transplant) or persons who obtain, store, or transplant organs.
• To the Food and Drug Administration (FDA) relating to problems with food, supplements, and products.
• To Comply With Workers’ Compensation Laws-if you make a workers’ compensation claim.
• For Public Health and Safety Purposes as Allowed or Required by Law:
  • to prevent or reduce a serious, immediate threat to the health or safety of a person or the public.
  • to public health or legal authorities
    • to protect public health and safety
    • to prevent or control disease, injury, or disability
    • to report vital statistics such as births or deaths.
• To Report Suspected Abuse or Neglect to public authorities.
• To Correctional Institutions if you are in jail or prison, as necessary for your health and the health and safety of others.
• For Law Enforcement Purposes such as when we receive a subpoena, court order, or other legal process, or you are the victim of a crime.
• For Health and Safety Oversight Activities. For example, we may share health information with the Department of Health.
• For Disaster Relief Purposes. For example, we may share health information with disaster relief agencies to assist in notification of your condition to family or others.
• For Work-Related Conditions That Could Affect Employee Health. For example, an employer may ask us to assess health risks on a job site.
• To The Military Authorities of U.S. and Foreign Military Personnel. For example, the law may require us to provide information necessary to a military mission.
• In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order.
• For Specialized Government Functions. For example, we may share information for national security purposes.

Appointment Reminders:

Unless you inform us in writing otherwise, we may call to remind you of a scheduled appointment. If you are not home we reserve the right to leave a reminder message either on an answering machine or with the person who answers. We will ONLY disclose the day and time of the appointment, not the reason for the appointment. We may also send out postcards reminding you it is time to make a follow up appointment, this reminder WILL NOT disclose the reason for the appointment.

Our Responsibilities:

• By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this Notice at any time as allowed by law. If we make changes, we will update this Notice and post it in our office. At your request, you may receive a copy of the revised policy.

Other Uses and Disclosures of Protected Health Information:

• Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

To Ask for Help or Complain:

• If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact our clinic Privacy Officer by calling or visiting the office.
• If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to our Privacy Officer. You may also file a complaint with the U.S. Secretary of Health and Human Services.
• We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.