WILLIAM KEHNE MOELLER, M.D.
Notice of Privacy Practices
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.
IF YOU HAVE ANY QUESTIONS ABOUT ANY PART OF THIS
NOTICE, PLEASE ASK TO SPEAK TO OUR PRIVACY OFFICER.
notice of Privacy Practices describes how we may use and disclose your
protected health information needed to treat you, obtain payment for services,
for health care operations and for other purposes permitted by law. The term
“protected health information” means any information about you, including
information that may identify you and relates to your past, present or future
physical or mental health or condition and related health care services.
practice provides this Notice to comply with the Privacy Regulations issued by
the Department of Health and Human Services in accordance with the Health
Insurance Portability and Accountability Act of 1996 (HIPAA). Our practice is
required to comply with the terms of this Notice of Privacy Practices.
Notice of Privacy Practices will apply to:
- Any health care professional
authorized to enter information into your chart (including physicians, RNs,
areas of the Practice (front desk, administration, billing and collection,
- All employees, staff and other personnel that work for or with our Practice;
- Our business associates(including a billing service, or facilities to which we refer patients),
on-call physicians, and so on.
CHANGES TO OUR
NOTICE OF PRIVACY PRACTICES
practice may change the terms of this Notice at any time. The new notice will
be effective for all protected health information that we maintain at that time
with the last revision date in the lower left corner. The current notice will
always be posted in our office and on our practice web site
www.moellerortho.com. To request a Notice of Privacy Practices at any
time you may:
Call the office at
678-344-4944 and request a copy be sent to you at your mailing address.
Ask for a copy at your next
visit to our office, or
Open our website and read
and/or print a copy of the current Notice
OUR COMMITMENT TO YOU:
understand that your medical information is personal to you, and we are
committed to protecting the information about you. You should be comfortable
in sharing any information about your health with your doctor in order to help
him/her provide the most appropriate health care. As our patient, we create
paper and electronic medical records about your health, our care for you, and
the services and/or items we provide to you as our patient. We need this
record to provide for your care and to comply with certain legal requirements.
of our medical and administrative staff understands that the practice is
required by law to:
make sure that the protected
health information about you is kept private;
provide you with a Notice of our
Privacy Practices and your legal rights with respect to protected health
information about you; and
follow the conditions of the
Notice that is currently in effect.
HOW YOUR MEDICAL INFORMATION MAY BE USED OR DISCLOSED
explanation is provided only to help you understand how the practice may use or
disclose your protected information not only to provide you with health care
services, but also to comply with any authorizations or disclosures required by
law. . For example, your medical information may be used for:
Medical Treatment. We will use medical information about you that was
on file prior to this notice or which may be obtained after this the date of
this Notice to provide, coordinate or manage your health care and any related
services. This includes the sharing information with others that have already
obtained your permission to have access to your protected health information.
We may also disclose medical information about you to doctors, nurses,
laboratory or imaging technicians, medical students, hospital or home health
personnel who are involved in taking care of you. We may also disclose
information to other doctors who may be treating you or to who we may refer you
for care. These doctors may need information from your medical record to
provide appropriate care.
areas of our practice also may share medical information about you including
your record(s), prescriptions, requests for lab work and x-rays. We may also
discuss your medical information with you to recommend possible treatment
options or alternatives that may be of interest to you. We also may disclose
medical information about you to people outside our practice who may be
involved in your medical care after you leave the practice; this may include
your family members, or other personal representatives authorized by you or by
a legal mandate (a guardian or other person who has been named to handle your
medical decisions, should you become incompetent).
Payment. We may use and
disclose medical information about you to for services and procedures in order
to create a bill or claim and collect payment from you, an insurance company,
or any other third party. For example, we may need to give health care
information about treatment you received at the Practice to the third parties
you identify to obtain payment or reimbursement for the care. We may also tell
your health plan and/or referring physician about a treatment you are going to
receive to obtain prior approval or to determine whether your plan will cover
the treatment or to facilitate payment to physician to who we may send or
receive a referral related to your care.
Health Care Operations.
We may use and disclose medical information about you so that we can run our
Practice more efficiently and make sure that all of our patients receive
quality care. These uses may include reviewing our treatment and services to
evaluate the performance of our staff, deciding what additional services to
offer and where, deciding what services are not needed, and whether certain new
treatments are effective. We may also disclose information to doctors, nurses,
technicians, medical students, and other personnel for review and learning
purposes. When we use an outside business, such as an accounting firm or
consultant to help in our business operations, we will advise them of their
continued obligation to maintain the privacy of your medical records.
Appointment and Patient Recall Reminders. We may
ask that you sign in at the Receptionists' Desk, on a " Sign In " log
on the day of your appointment with the Practice. We may use and disclose
medical information to contact you as a reminder that you have an appointment
for medical care with the Practice, or that you are due to receive periodic
care from the Practice. This contact may be by phone, in writing, or otherwise
and may involve the leaving of a message on an answering machine, which could
be received or intercepted by others. Please let us know, in writing, if this
is not acceptable or if there is another telephone number, or method of
notification you prefer.
Emergency Situations & Disaster Relief. We may
disclose medical information about you to an organization assisting in a
disaster relief effort or in an emergency situation so that your family can be
notified about your condition, status and location.
Research. Under certain circumstances, we may use and
disclose medical information about you for research purposes regarding
medications, efficiency of treatment protocols and the like. All research
projects are subject to an approval process, which evaluates a proposed
research project and its use of medical information. Before we use or disclose
medical information for research, we will obtain an Authorization from to
disclose your individually identifiable health information, unless the
authorization requirement has been waived. If possible, we will make the
information non-identifiable to a specific patient. If the information has
been sufficiently de-identified, an authorization for the use or disclosure is
Required By Law. We will disclose medical information about you when
required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about
you when necessary to prevent a serious threat either to your specific 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 the threat.
Organ and Tissue Donation. If you are an organ donor,
we may release medical 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.
Workers' Compensation. We may release medical information about you for
workers' compensation or similar programs in accordance with State law. These
programs provide benefits for work-related injuries or illness.
Public Health Risks. Law
or public policy may require us to disclose medical information about you for
public health activities. These activities generally include the following:
- to prevent or control disease, injury or disability;
- to report births and deaths;
- to report suspected child abuse or neglect;
- to report reactions to medications or problems with products;
- to notify people of recalls of products they may be using;
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
- to notify the appropriate government authority if we believe a patient has been the victim of abuse,
neglect or domestic violence. We will only make this disclosure if you agree or
when required or authorized by law.
Investigation and Government Activities. We may
disclose medical information to a local, state or federal agency for activities
authorized by law. Examples include audits, investigations, inspections, and licensure.
These activities are necessary for the payer, the government and other
regulatory agencies to monitor the health care system, government programs, and
compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we
may disclose medical information about you in response to a court or
administrative order. We may also disclose medical information about you in
response to other lawful procedures by someone else involved in the dispute.
We shall attempt in these cases to tell you about the request so that you may
obtain an order protecting the information requested if you so desire. We may
also use such information to defend ourselves or any member of our Practice in
any actual or threatened action.
Law Enforcement. We may release medical information if asked to do so
by a law enforcement official:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- Concerning the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the Practice; and
- 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. We may release medical 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 medical information
about patients of the Practice to funeral directors, as necessary to carry out
Inmates. If you are an inmate of a correctional institution
or under the custody of a law enforcement official, we may release medical
information about you to the correctional institution or law enforcement
official. This release would be necessary (1) for the institution to provide
you with health care; (2) to protect your health and safety or the health and
safety of others; or (3) for the safety and security of the correctional
OTHER USES OF MEDICAL INFORMATION.
uses and disclosures of medical information not covered by this notice or the
laws that apply to us will be made only with your written permission, unless
those uses can be reasonably inferred from the intended uses above.
YOU HAVE THE RIGHT TO REVOKE AN AUTHORIZATION
you have provided us with your permission to use or disclose medical
information about you, you may revoke that permission, in writing, at any time.
If you revoke your permission, we will no longer use or disclose medical
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 with your permission, and that we are required to retain our
records of the care that we provided to you.
you believe your privacy rights have been violated, you may file a complaint
with the Practice or with the Secretary of the Department of Health and Human
Services. To file a complaint with the Practice, contact our office manager,
who will direct you on how to file an office complaint. The Office Manager can
be reached at this number 678-344-4944. All complaints must be submitted in
writing. You will receive a written reply after the investigation. You will
not be penalized for filing a complaint.
THIS SECTION DESCRIBES YOUR RIGHTS AND THE OBLIGATIONS OF
THIS PRACTICE REGARDING THE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION.
have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy medical
information that may be used to make decisions about your care. This includes
your own medical and billing records. Upon proof of an appropriate legal
relationship or designation as your Personal Representative, records may be
inspected by others involved with your care or for which you have a guardian or
To inspect and copy your medical record, you must
submit your request in writing to our Privacy Officer. Call or ask the front
desk person for the name of the Privacy Officer. If you request a copy of the
information, we may charge a fee for the costs of copying, mailing or other
supplies (tapes, disks, etc.) associated with your request.
We may deny your request to inspect and copy in certain
very limited circumstances. If you are denied access to medical information,
you may request that our Compliance Committee review the denial. Another
licensed health care professional chosen by the Practice will review your
request and the denial. The person conducting the review will not be the person
who denied your request. We will comply with the outcome and recommendations
from that review.
You may also request that we send your records
directly to another health care provider for review and determination of
disclosure to you.
Right to Amend. If you
feel that the medical information we have about you in your record is incorrect
or incomplete, then you may ask us to add an amendment to your record following
the procedure below. You have the right to request an amendment for as long as
the Practice maintains your medical record.
To request an
amendment, your request must be submitted in writing, along with your requested
amendment and a reason that supports your request to amend. The amendment must
be dated and signed by you and notarized.
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
Is not part of the medical
information kept by or for the Practice;
Is not part of the information
which you would be permitted to inspect and
Is inaccurate or incomplete.
Right to an Accounting of
Disclosures. You have the right to request an " accounting of
disclosures " made by this practice after April 14, 2003. This is a list of
the disclosures of your medical information we made to others that are not
involved with your treatment, payment of services rendered to you or health
care operations, as previously defined in this Notice of Privacy Practices, for
an example, disclosures requested by court order or to a life insurance company
on your authorization.
this list, you must submit your request in writing. Your request must state a
time period not longer than six (6) years back and may not include dates before
April 14, 2003. Your request should indicate in
what form you want the list (for example, on paper or on computer disk). 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 Request
Restrictions. You have the right to request a restriction or
limitation on the medical 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 medical information we disclose about you to someone who
is involved in your care or the payment for your care (a family member or
friend). For example, you could ask that we not use or disclose information
about a particular treatment you received.
We are not required to agree to your request and we
may not be able to comply with your request. If we do agree, we will
comply with your request, except that we shall not comply, even with a written
request, if we are otherwise required to disclose the information by law.
To request restrictions, you must make your request in
writing. In your request, you indicate:
what information you want to
whether you want to limit our
use, disclosure or both; and
to whom you want the limits to
apply, (e.g., disclosures to your children, parents, spouse, etc.)
Right to Request
Confidential Communications. You have the right to request that we communicate
with you about medical matters in a certain way or at a certain location. For
example, you can ask that we only contact you at work, or by mail, or that we
not leave messages on voice mail or e-mail, etc.
confidential communications, you must make your request in writing. 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 us to contact you.
Right to a Paper Copy of
This Notice. You have the right
to a paper 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