OF PRIVACY PRACTICES
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR PERSONAL HEALTH INFORMATION.
PLEASE REVIEW THIS INFORMATION CAREFULLY.
This notice is being
published in response to a 1996 Congressional measure called Health
Information Privacy and Accountability Act (HIPAA). Dubuque Obstetrics
& Gynecology, P.C. has and continues to respect patient confidentiality.
HIPAA has outlined new standards and this handout addresses our
current office procedures in relation to the regulations.
Provision of Notice:
Dubuque Obstetrics & Gynecology, P.C. provides a Notice of Privacy
Practices to every patient with whom it has a direct treatment relationship.
The Notice is provided on the first date in our office after April
13, 2003 or at any time upon request. The notice is also posted
on our web site: www.dbqobgyn.com.
Provision of Notice: When a direct treatment patient receives
the Notice, we ask the patient to acknowledge receipt by signing
an adhesive form to be filed in the patient medical record. If the
patient refuses to sign the form, the refusal is noted on the label
and placed in the patient medical record.
Effective Date and
Changes to Notice: This Notice is effective April 14, 2003.
The practice reserves the right to revise this Notice at any time.
Updated copies will be available at your request in our office and
posted on our web site: www.dbqobgyn.com.
Obstetrics & Gynecology, P.C. allows all patients and their agents
to file complaints with the practice and with the Secretary of the
Department of Health and Human Services (DHHS) whenever he or she
believes that the practice has violated their rights. Complaints
to the practice must be in writing, must describe the acts or omissions
that are the subject of the complaint, and must be filed within
180 days of the time the patient became aware or should have become
aware of the violation. Complaints must be addressed to the attention
of the Privacy Officer at Dubuque Obstetrics & Gynecology, P.C.
The practice investigates each complaint and may, at its discretion,
reply to the patient or the patient's agent. The practice does not
take any adverse action against any patient who files a complaint
against the practice.
The practice has a Privacy Officer that serves as the contact person
for all issues related to the Privacy Rule. The Privacy Officer
is the Office Manager. If you have any questions about this Notice,
please contact: Dubuque Obstetrics & Gynecology, P.C. Attn: Privacy
Officer 1500 Delhi Street, Ste 3100 Dubuque, Iowa 52001-6319
USES AND DISCLOSURES
OF PROTECTED INFORMATION
Uses and Disclosures
- Treatment, Payment, and Healthcare Operations Dubuque Obstetrics
& Gynecology, P.C. uses and discloses protected health information
(PHI) for payment, treatment, and healthcare operations.
includes activities related to providing and coordinating services
to the patient. Examples include discussing care plans with medical
/ midwifery students, pharmacists and hospitals.
relates to all activities associated with getting reimbursed for
services provided, including submission of claims to insurance
companies and any additional information requested by the insurance
company so they can determine if they should pay the claim. We
also may use and disclose your PHI to obtain payment from third
parties that may be responsible for such costs, such as family
members. Also we may use your PHI to bill you directly for services
- Healthcare operations
support our daily operations as a quality healthcare provider.
Examples include utilizing your PHI to evaluate the quality of
care you received from us.
Uses and Disclosures
- Not Requiring Authorization Dubuque Obstetrics & Gynecology
may use PHI without your authorization in the following circumstances:
- Disclosure to
those involved in an individual's care is allowed when
the patient approves or, when the patient is not present or not
able to approve, when such disclosure is deemed appropriate in
the professional judgment of the practice;
- Use and disclosure
for courtesy appointment reminders;
- Uses and disclosures required by law include disclosing
protected health information to public health officials. Examples
of this include reporting of communicable diseases (i.e. sexually
transmitted diseases), medical conditions or procedures including
miscarriages. We are also required to report suspected abuse or
- For health oversight activities: involves information
used and released for audits, investigations, licensure issues,
and other health oversight activities;
- For judicial and administrative proceedings;
- For law enforcement purposes;
- Related to deceased individuals, such as PHI required for
identification by a coroner or medical examiner and funeral directors
as required by law. The attending physician is required to sign
the death certificate and provide the coroner with a copy of the
decedent's protected health information.
- Related to cadaveric
organ, eye or tissue donations;
- Uses and disclosures to avert a serious threat to health or
- Uses and disclosures for specialized government functions;
- Uses and Disclosures in Emergency Situations: The practice
uses and discloses protected health information as appropriate
to provide treatment in emergency situations.
Uses and Disclosures
- Do Not Apply to Practice
- Research: The
practice does not engage in any research activities that require
it to use or disclose protected health information.
- Other Uses and
Disclosures: The practice does not use or disclose protected
health information to an employer or health plan sponsor, for
underwriting and related purposes, to brokers and agents unless
authorized by the patient.
- Accounting for Disclosures of Protected Health Information
The practice tracks disclosures of a patient's protected health
information. Disclosures not tracked include: treatment, payment,
healthcare operations, disclosures made to the patient or a person
involved in the patient's care, disclosures as a result of a patient
authorization, disclosures for national security or intelligence
purposes, to correctional institutions and to law enforcement officials.
A form to request an accounting of disclosures can be received by
contacting the Privacy Officer.
- Inspect and Copy Protected Health Information The practice
allows individuals to inspect and copy their protected health information
and charges a reasonable fee for the inspection of and copying of
records. A form to request an inspection or copy can be made by
contacting the Privacy Officer.
- Request Amendment to Protected Health Information The practice
allows an individual to request that the practice amend the protected
health information maintained in the patient's medical record or
the patient's billing record. The requests must be in writing and
should be marked "Attention: Privacy Officer."
- Request Confidential Communications The practice accommodates
all reasonable requests to keep communications confidential. The
practice determines the reasonableness based on the administrative
difficulty of complying with the request. A request for confidential
communications must be in writing, must specify an alternative address
or other method of contact, and must provide information about how
payment will be handled. The request must be addressed to the practice's
Privacy Officer. No reason for the request needs to be stated. The
practice accommodates all reasonable requests.
- Request Restriction of Disclosures The practice accepts requests
for restrictions of disclosures of protected health information.
All requests for restrictions of disclosures must be submitted in
writing and sent to the attention of the practice's Privacy Officer.
The Privacy Officer notifies the requestor in writing of the practice's
response to the request.
- Authorizations The practice obtains a written authorization
from a patient or the patient's representative for the use or disclosure
of protected health information for other than treatment provided
by or recommended by our providers, payment, or healthcare operations.
In Iowa, a specific written authorization is required to disclose
or release mental health, substance abuse (alcohol and drug) or
An individual may revoke
an authorization at any time. The revocation must be in writing
and must be sent to the attention of Privacy Officer; however, the
practice may have already disclosed or used the information prior
- Waiver of Rights The practice never requires an individual
to waive any of his or her individual rights as a condition for
the provision of treatment, except under very limited circumstances
allowed under law.