Notice of Privacy Practices
for Protected Health Information
Locke Family Medicine(LFM)
Effective Date: 17 August 2007
This notice describes how medical information about you may be used and
and how you can get access to this information.
** Please review it carefully! **
LFM is permitted
by federal privacy laws to make uses and disclosures of your health information
for purposes of treatment, payment, and health care operations. Protected
health information is the information we create and obtain in providing our
services to you. Such information may include documenting your symptoms,
examination, and test results, diagnoses, treatment, and applying for future
care or treatment. It also includes billing documents for those services.
of Uses of Your Health Information for Treatment Purposes are:
nurse obtains treatment information about you and records it in a
the course of your treatment, the physician determines he/she will
need to consult with another specialist in the area. He/she will
share the information with such specialist and obtain his/her input.
of Use of Your Health Information for Payment Purposes:
of Use of Your Information for Health Care Operations:
obtain services from our insurers or other business associates such
as quality assessment, quality improvement, outcome evaluation,
protocol and clinical guideline development, training programs,
credentialing, medical review, legal services, and insurance. We
will share information about you with such insurers or other
business associates as necessary to obtain these services.
Your Health Information Rights
The health and
billing records we maintain are the physical property of the LFM. The
information in it, however, belongs to you. You have a right to:
Request a restriction on certain uses and disclosures of your health
information by delivering the request to LFM’s office -- we are not required
to grant the request, but we will comply with any request granted;
Obtain a paper copy of the current Notice of Privacy Practices for Protected
Health Information ("Notice") by making a request at LFM’s office;
you be allowed to inspect and copy your health record and billing record –
you may exercise this right by delivering the request to LFM’s office;
denial of access to your protected health information, except in certain
your health care record be amended to correct incomplete or incorrect
information by delivering a request to LFM’s office. We may deny your
request if you ask us to amend information that:
created by us, unless the person or entity that created the information
is no longer available to make the amendment;
part of the health information kept by or for LFM;
part of the information that you would be permitted to inspect and copy;
accurate and complete.
If your request
is denied, you will be informed of the reason for the denial and will have an
opportunity to submit a statement of disagreement to be maintained with your
communication of your health information be made by alternative means or at
an alternative location by delivering the request in writing to LFM’s
authorizations that you made previously to use or disclose information by
delivering a written revocation to LFM’s office, except to the extent
information or action has already been taken.
If you want to
exercise any of the above rights, please contact Kelly
Locke, MD, in person or in writing, during regular, business hours.
Dr. Locke will inform you of the steps that need to be taken
to exercise your rights.
privacy of your health information as required by law;
Provide you with a notice as to our duties and privacy practices as to the
information we collect and maintain about you;
Abide by the terms of this Notice;
Notify you if we cannot accommodate a requested restriction or request; and,
Accommodate your reasonable requests regarding methods to communicate health
information with you.
We reserve the
right to amend, change, or eliminate provisions in our privacy practices and
access practices and to enact new provisions regarding the protected health
information we maintain. If our information practices change, we will amend our
Notice. You are entitled to receive a revised copy of the Notice by calling and
requesting a copy of our "Notice" or by visiting our office and picking up a
To Request Information or File
If you have questions, would like
additional information, or want to report a problem regarding the handling of
your information, you may contact our Dr. Kelly Locke at
970-279-4111, 1450 East Valley Road, Ste 101, Basalt, CO 81621.
Additionally, if you believe your
privacy rights have been violated, you may file a written complaint at our
office by delivering the written complaint to Dr. Kelly
Locke at 970-279-4111, 1450 East Valley Road, Ste 101, Basalt, CO 81621.
You may also file a complaint by mailing it or e-mailing it to the Secretary of
Health and Human Services, whose street address and e-mail address is:
Office for Civil Rights - U.S.
Department of Health and Human Services [http://www.hhs.gov/ocr/hipaa/]
- 200 Independence Avenue S.W. - Room 509F, HHH Building - Washington, D.C.
We cannot, and will not, require
you to waive the right to file a complaint with the Secretary of Health and
Human Services (HHS) as a condition of receiving treatment from our
We cannot, and will not, retaliate
against you for filing a complaint with the Secretary of Health and Human
Other Disclosures and Uses
Communication with Family
Using our best judgment, we may disclose to a family member, other relative,
close personal friend, or any other person you identify, health information
relevant to that person's involvement in your care or in payment for such
care if you do not object or in an emergency.
Unless you object, we may use or disclose your protected health information
to notify, or assist in notifying, a family member, personal representative,
or other person responsible for your care, about your location, and about
your general condition, or your death.
Organ Procurement Organizations
Consistent with applicable law, we may disclose your protected health
information to organ procurement organizations or other entities engaged in
the procurement, banking, or transplantation of organs for the purpose of
tissue donation and transplant.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to
adverse events with respect to food, supplements, products and product
defects, or post-marketing surveillance information to enable product
recalls, repairs, or replacements.
by law, we may disclose your protected health information to public health
or legal authorities charged with preventing or controlling disease, injury,
or disability; to report reactions to medications or problems with products;
to notify people of recalls; to notify a person who may have been exposed to
a disease or who is at risk for contracting or spreading a disease or
Abuse & Neglect
We may release
health information about you to your employer if we provide health care
services to you at the request of your employer, and the health care
services are provided either to conduct an evaluation relating to medical
surveillance of the workplace or to evaluate whether you have a work-related
illness or injury. In such circumstances, we will give you written notice
of such release of information to your employer. Any other disclosures to
your employer will be made only if you execute a specific authorization for
the release of that information to your employer.
We may disclose your protected health information for law enforcement
purposes as required by law, such as when required by a court order, or in
cases involving felony prosecution, or to the extent an individual is in the
custody of law enforcement.
disclose your protected health information in the course of any judicial or
administrative proceeding as allowed or required by law, with your
authorization, or as directed by a proper court order.
To avert a
serious threat to health or safety, we may disclose your protected health
information consistent with applicable law to prevent or lessen a serious,
imminent threat to the health or safety of a person or the public.
For Specialized Governmental
disclose your protected health information for specialized government
functions as authorized by law such as to Armed Forces personnel, for
national security purposes, or to public assistance program personnel.
Medical Examiners, and Funeral Directors
We may release
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 patients to funeral directors
as necessary for them to carry out their duties.
Other uses and
disclosures, besides those identified in this Notice, will be made only as
otherwise required by law or with your written authorization and you may
revoke the authorization as previously provided in this Notice under "Your
Health Information Rights."
upon Copic HIPAA Form:
11 November 2007