Notice of Privacy Practices

Effective 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.

OUR RESPONSIBILITIES

JWM Neurology, P.C. takes the privacy of your health information seriously. We are required by law to maintain that privacy and to provide you with this Notice of Privacy Practices. This Notice is provided to tell you about our duties and practices with respect to your information. We are required to abide by the terms of this Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

The following categories describe different ways that we use and disclose your health information. For each category we explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• For Treatment.We may use health information about you to provide you with treatment, health care or other related services. We may disclose your health information to doctors, nurses, aids, technicians or other employees who are involved in taking care of you. Additionally, we may use or disclose your health information to manage or coordinate your treatment, health care or other related services. (Example: releasing information to a specialist or testing facility)
• For Payment. We may use and disclose your health information to bill and collect for the treatment and services we provide to you. We may send your health information to an insurance company or other third party for the payment purposes including to a collection service. (Example: Submitting claims to insurance on file, responding to appeals and requests for external reviews, determining eligibility, pre-certifying/pre-authorizing testing and hospital admissions)
• For Health Care Operations. We may use and disclose your health information for health care operations. These uses and disclosures are necessary to run JWM Neurology, P.C., to make sure you receive competent, quality health care, and to maintain and improve the quality of health care we provide. We may also provide your health information to various governmental or accreditation entities to maintain our license and accreditation. (Example: Reporting communicable diseases as required by law)
• Incidental Uses and Disclosures. We may occasionally inadvertently use or disclose your medical information when such a use or disclosure is incident to another use or disclosure that is permitted or required by law. For example, while we have safeguards in place to protect against others overhearing our conversations that take place between doctors, nurses or other JWM Neurology, P.C. personnel, there may be times that such conversations are in fact overheard. Please be assured, however, that we have appropriate safeguards in place to avoid such situations, and others, as much as possible.
• Disclosures to You. Upon request by you, we may use or disclose your medical information in accordance with your request.
• Limited Data Sets. We may use or disclose certain parts of your medical information, called a “limited data set,” for purposes of research, public health reasons or for our health care operations. We would disclose a limited data set to third parties that have provided us with satisfactory assurances that they will use or disclose your medical information only for limited purposes.
• Disclosures to the Secretary of Health and Human Services. We might be required by law to disclose your medical information to the Secretary of Health and Human Services, or his/her designee, in the case of a compliance review to determine whether we are complying with privacy laws.
• De-Identified Information. We may use your medical information, or disclose it to a third party whom we have hired, to create information that does not identify you in any way. Once we have de-identified your information, it can be used or disclosed in any way according to law.
• Disclosures by Members of Our Workforce. Members of our workforce, including employees, volunteers, trainees or independent contractors, may disclose your medical information to a health oversight agency, public health authority, health care accreditation organization or attorney hired by the workforce member, to report the workforce member’s belief that we have engaged in unlawful conduct or that our care or services could endanger a patient, workers, or the public. In addition, if a workforce member is a crime victim, the member may disclose your medical information to a law enforcement official.
• As Required By Law. We will disclose your health information when required to do so by federal, state or local law.
• For Public Health Purposes. We may disclose your health information for public health activities. While there may be others, public health activities generally include the following:
  • Preventing or controlling disease, injury or disability
  • Reporting births and deaths;
  • Reporting defective medical devices or problems with medications;
  • Notifying people of recalls of products they may be using; and
  • Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
• Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities might include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government benefit programs, and compliance with civil rights laws.
• Judicial Purposes. We may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in a dispute, but only if efforts have been made to tell you about the request, in which you were given an opportunity to object to the request, or to obtain an order protecting the information requested.
• Law Enforcement. We may release health information if asked to do so by a law enforcement official, if such disclosure is:
  • Required by law;
  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at the Covered Entity; or
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
• Coroners, Medical Examiners and Funeral Directors. In certain circumstances, we may disclose health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about individuals to funeral directors as necessary to carry out their duties.
• Organ and Tissue Donation. We may disclose your health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
• Research. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all individuals who received one medication to those who received another. All research projects, however, are subject to a special approval process. This process includes evaluating a proposed research project and its use of health information, trying to balance the research needs with your need for privacy of your health information. Before we use or disclose health information for research, the project will have been approved through this research approval process. Additionally, when it is necessary for research purposes and so long as the health information does not leave JWM Neurology, P.C. we may disclose your health information to researchers preparing to conduct a research project, for example, to help the researchers look for individuals with specific health needs. Lastly, if certain criteria are met, we may disclose your health information to researchers after your death when it is necessary for research purposes.
• To Avert a Serious Threat to Health or Safety. We may use and disclose your health information when we believe it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent or lessen the threat or to law enforcement authorities in particular circumstances.
• Military and Veterans. If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
• National Security and Intelligence Activities. We may release your health information to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities authorized by law.
• Protective Services for the President and Others. We may disclose your health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or for the conduct of special investigations.
• Custodial Situations. If you are an inmate in a correctional institution and if the correctional institution or law enforcement authority makes certain representations to us, we may disclose your health information to a correctional institution or law enforcement official.
• Workers’ Compensation. We may disclose your health information as authorized by and to the extent necessary to comply with workers’ compensation laws or laws relating to similar programs.
• Suspected Abuse or Neglect. If we believe that a person is a victim of child abuse or neglect, we are required by law to report certain information to public authorities.
• Communications Regarding Our Services or Products. We may use and disclose your health information to make a communication to you to describe a health-related product or service of JWM Neurology, P.C. In additions, we may use or disclose your health information to tell you about products or services related to your treatment, case management or care coordination, or alternative treatments, therapies, providers, or settings of care for you. We may occasionally tell you about another company’s products or services, but will use or disclose your health information for such communications only if they occur in person with you. We may also use or disclose your health information to give you a promotional gift from us that is of minimal value.
• Treatment Alternatives, Appointment Reminders and Health-Related Benefits. We may use and disclose your health information to tell you about or recommend possible treatment alternatives or health-related benefits or services that may be of interest to you. Additionally, we may use and disclose your health information to provide appointment reminders. If you do not wish us to contact you about treatment alternatives, health-related benefits or appointment reminders, you must notify us in writing, and state which of those activities you wish to be excluded from.
• Individuals Involved in Your Care or Payment for Your Care. We may release health information about you to a family member, other relative, or any other person identified by you who is involved in your health care. We may also give information to someone who is involved with or helps pay for your care. We may also tell your family, friends, personal representative or other person responsible for your health care your condition and that you are at the Hospital.
• Third Parties. We may disclose your health information to third parties with whom we contract to perform services on our behalf. If we disclose your information to these entities, we will have an agreement by them to safeguard your information.
• Disclosures of Records Containing Drug or Alcohol Abuse Information. Because of federal law, we will not release your medical information if it contains information about drug or alcohol abuse without your written permission except in very limited situations.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose your health information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made under the authorization, and that we are required to retain our records of the care that we provided to you.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights regarding health information we maintain about you:

• Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
  To request restrictions, you must make your request in writing to Ellise Hayden, Chief Operating Officer, 6983 Hillsdale Court, Indianapolis, Indiana 46250. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.
• Right to Request Confidential Communications. You have the right to request that we communicate with you or your responsible party about your health care in an alternative way or at a certain location. To request confidential communications, you must make your request in writing to Ellise Hayden, Chief Operating Officer, 6983 Hillsdale Court, Indianapolis, Indiana 46250. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. To inspect and copy health information that may be used to make decisions about you, you can submit your request in writing or orally to Ellise Hayden, Chief Operating Officer, 6983 Hillsdale Court, Indianapolis, Indiana 46250. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
• Right to Amend. You have the right to ask us to amend your health and/or billing information for as long as the information is kept by us.
  To request an amendment, your request must be made in writing and submitted to Ellise Hayden, Chief Operating Officer, 6983 Hillsdale Court, Indianapolis, Indiana 46250. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the health information kept by or for us;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.
• Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures that we have made of your health information. To request this list of disclosures, you must submit your request in writing to Ellise Hayden, Chief Operating Officer, 6983 Hillsdale Court, Indianapolis, Indiana 46250. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a twelve-month period will be free. For additional lists, during such twelve-month period, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
• Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice at our web site at www.jwmneuro.com. To obtain a paper copy of this Notice, contact Ellise Hayden, Chief Operating Officer, 6983 Hillsdale Court, Indianapolis, Indiana 46250.

WHO THIS NOTICE APPLIES TO

This Notice describes JWM Neurology, P.C.’s practices and those of:

• Any health care professional authorized to enter information into or consult your medical record.
• All departments and units of JWM Neurology, P.C.
• Any member of a volunteer group we allow to help you.
• All employees, staff and other JWM Neurology, P.C.’s personnel.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice. We reserve the right to make the revised Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in a clear and prominent location to which you have access. The Notice is also available to you upon request. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, if we revise the Notice, you may request a copy of the current Notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with JWM Neurology, P.C. or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact Ellise Hayden, Chief Operating Officer, at 6983 Hillsdale Court, Indianapolis Indiana, 46250. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

If you have any questions about this Notice, please contact:

Ellise Hayden
Chief Operating Officer
317-308-2800, Extension 1602

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