As required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAYBE BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
If you have any questions about this notice please contact our privacy contact who is
SIMON Y. SU, MD 109 N 9TH ST PHILADELPHIA, PA 19107-1832 215-923-2810
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Our practice is dedicated to maintaining the privacy of your protected health information.
We are required to abide by the terms of this Notice of Privacy Practices. We may revise or amend the terms of our notice, at any time. The new notice will be effective for all protected health information that we have at that time and for future information. We will post our current Notice in our office in a visible location at all times and upon your request, we will provide you with any revised Notice.
1. Uses and Disclosures to carry out treatment, payment or health care operations:
Under HIPAA regulations, we do not need to obtain permission to use health information for treatment, payment and health care operations.
We may use and disclose your Protected Health Information (PHI) for the following reasons:
Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party.
For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, certain fundraising activities within our practice, and conducting or arranging for other business activities.
For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you.
We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
Appointment Reminders We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
Treatment Options and Services We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. However, we will get a written authorization from you for further marketing purposes.
2. Uses and disclosures that you can agree or object to
We may use and disclose your protected health information in the following instances, which you have the opportunity to object to.
Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Emergencies We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall allow you to object to future disclosures as soon as reasonably practicable after the delivery of treatment.
3. Uses and disclosures that we will obtain your written authorization for
Psychotherapy Notes we may only disclose your psychotherapy notes for limited purposes such as carrying out treatment. For other purposes we will obtain your written consent.
Marketing for most marketing purposes we will obtain your written consent; exceptions include if the product or service is directly treatment related, discussed face-to-face or given as a promotional gift of nominal value.
Uses and Disclosures of Your Highly Confidential Information Certain Pennsylvania laws require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental illness, mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment, and referral; (4) is about HIV/AJDS testing, diagnosis or treatment; (5) is about counseling for sexual assault; (6) is to be reported to the State DNA Data Bank. Under Pennsylvania law, we must generally get your authorization to disclose Highly Confidential Information about you, but we may disclose it without first getting your authorization in the following circumstances:
i)Mental health treatment. We may disclose information from your mental health treatment records to those who are providing you with treatment. We may also disclose information from your mental health treatment records to someone you identify as being responsible for paying for your care, such as an insurance company, but we will only disclose the limited amount of information necessary for our payment purposes. We may disclose information from your mental health treatment records to the County Mental Health Administrator, a Mental Health Review Officer or to an attorney representing you at a commitment hearing. We may disclose information from your mental health treatment records when we are required to do so by law, such as to meet our requirement to report suspected child abuse. Regulators such as licensing agencies may review our organization from time to time, and they may have access to your mental health treatment records during those reviews. Other legally authorized reviewers may also review the care and services we have provided, and they may need to have us disclose information from your mental health records to them. We may disclose information from your mental health treatment records if we are ordered by a court to do so. If you are older than 14 but younger than 18, we may need to release your mental health treatment records to your parent or guardian, if you need medical care that they must agree to. In an emergency, we may release information from your mental health treatment records in order to prevent someone (including you) from being harmed.
ii) Drug and alcohol treatment records. We may disclose information from your drug and alcohol treatment records to a judge who has sentenced you, if your being in treatment is a condition of the sentence. We may also disclose information from your drug and alcohol treatment records to a judge who has assigned you to a drug and alcohol treatment program under a pre-sentence conditional release program. We may also disclose information from your drug and alcohol treatment records to your probation or parole officer, if your probation or parole is conditioned on you being in treatment. In all other cases, we will get your authorization before we release information from your drug and alcohol treatment records. But if you have a medical emergency, we may release information from your drug and alcohol treatment records to proper medical authorities so that they may provide medical treatment to you.
iii) HIV-related information. If you are HIV-positive, we will generally not disclose information about you that would identify you as being HIV-positive. Certain medications, for example, are typically only given to HIV-positive persons. If you were receiving such a medication, that information would not generally be disclosed by us without your authorization. We may, however, without your authorization, disclose HIV-related information to a physician who ordered an HIV test, or to health care or social service providers who are providing you with care and services. We may disclose your WV-related information to your health insurer, so that we can get paid for the care and services we are providing to you. We may disclose HIV-related information to persons or organizations who review our services for peer review, accreditation, licensure, or other oversight activities. We may disclose fly-related information about you when we are required to do so by law—for instance, to the Department of Health. We may disclose your fly-related information to a person so named in a court order. In the event of your death, we may disclose your HIV-related information to the funeral director who will receive your body. If we are pursuing youth residential placement for you, we may also disclose your HIV-related information to certain county agencies or facilities to help coordinate this placement.
iv) Sexual assault counseling records. If we provide you with sexual assault victim counseling, we will not release or disclose those records without your authorization.
v) Results of DNA Testing. If we perform DNA testing on you for purposes of reporting to the State DNA Data Bank, we are only permitted to disclose the results of that testing to the Data Bank authorities who are authorized to receive it.
4. Uses and disclosures for which and authorization or opportunity to agree or object to is not required
We may use or disclose your protected health information in the following situations:
Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is required or permitted by law to receive the information. The disclosure will be made for the purpose of controlling or reporting disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Maintenance of Vital Records: We may report data such as births and deaths.
Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Otherwise, we will ask for a written authorization from you.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. This may not include psychotherapy notes. You must submit your request in writing to Simon Y. Su, MD, 109 N 9th St, Philadelphia, PA 19107, ATT: Office Manager in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
Please contact Jane Chen, RN, Office manager at 215-923-2810 if you have questions about access to your medical record.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by Filling the restriction form provided in this office to instruct us how to restrict your PHI.
You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Simon Y. Su, MD, 109 N 9th St, Philadelphia, PA 19107, ATT: Office Manager specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, for example if we think the information is correct, or was not created by our practice, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact to determine if you have questions about amending your medical record. To file an amendment, your request must be in writing and must be submitted to Simon Y. Su, MD, 109 N 9th St, Philadelphia, PA 19107, ATT: Office Manager.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. Accounting is not required for disclosures we may have made to you, incidental disclosures, disclosures you have authorized, disclosures for a facility directory, disclosures to family members or friends involved in your care, or disclosures made to carry out treatment, payment or health care operations. You have the right to receive specific information regarding disclosures that occurred after April 14, 2003 up to a six year timeframe. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
In order to obtain an accounting of disclosures, you must submit your request in writing to Simon Y. Su, MD, 109 N 9th St, Philadelphia, PA 19107, ATT: Office Manager. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
You have a right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices even if you have agreed to receive an electronic copy of the Notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact to Simon Y. Su, MD, 109 N 9th St, Philadelphia, PA 19107, ATT: Office Manager.
You have a right to file a complaint if you believe your privacy rights have been violated. You may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Simon Y. Su, MD, 109 N 9th St, Philadelphia, PA 19107, ATT: Office Manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
This notice was published and becomes effective on April 14, 2003.
SIMON SU, MD
109 N 9th St
Philadelphia, PA 19107