Maple Grove Medical, Inc.
Maple Grove Medical, Inc.
"Bringing peace of mind home"
HIPAA 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.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) 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” 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.
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information 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 would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. 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, 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 may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by Law, Public Health issues as required by law, Communicable Diseases, Health Oversight: Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation: Research, Criminal Activity, Military Activity and National Security, Worker’s Compensation. Inmates: 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.
Other permitted and required uses and disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Your rights
Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
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 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 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. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have your physician amend your protected health information. 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.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before November 29, 2010.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.
Patient Rights and Responsibilities
STATEMENT OF PATIENT RIGHTS
Patients have the right to be treated with dignity and respect.
Patients have the right to fair treatment regardless of race, religion, gender, ethnicity, age, disability, or source of payment.
Patients have the right to have their treatment and other information kept private.
Only in life-threatening situations or if required by law, can records be released without a signed consent from patients.
Patients have the right to information from staff/providers in a language they can understand.
Patients have the right to an easy to understand explanation of their condition and treatment.
Patients have the right to know all about their treatment choices regardless of cost coverage.
Patients have the right to get information about services offered by their providers and patient role in the treatment process.
Patients have the right to request professional information about their provider.
Patients have the right to know the clinical guidelines used in providing and/or managing their care.
Patients have the right to provide suggestions on office policies and procedure.
Patients have the right to complain and to know about the complaint, grievance, and appeals processes.
Patients have the right to know about State and Federal laws governing their rights and responsibilities.
Patients have the right to participate in the formation of their plan of care.
STATEMENT OF PATIENT RESPONSIBILITIES
If you miss two or more consecutive appointments without good reason and without informing our office, you will not be considered as an active patient with our system. We understand that you are terminating services with us - let us know if we can be of any help arranging alternative services for you.
Sign the medication consent forms to take medication prescribed by your psychiatrist.
In case of after-hours emergency, call 911. To reach your provider during regular business hours, please use the following number provided:
Office 8:30am – 5:00pm, Monday-Friday (804) 955-0965
Patients are responsible for providing their medical provider with accurate information needed to deliver quality care.
Patients are responsible for informing their provider when/if their treatment plan is no longer effective.
Patients are responsible to follow their treatment plans and to inform their provider of any changes to the treatment plan made by other providers including any changes in their medications.
Patients are responsible for reviewing their care and treatment plans continuously and reporting effectiveness or ineffectiveness of the care plan to their provider.
Patients are responsible for treating those giving them care with dignity and respect.
Patients should not be involved in any conscious behavior that could harm the lives of their provider, office staff, or other patients.
Patients are responsible for keeping their appointments, arriving on time, and notifying the office of any cancellation at least 24 hours prior to the appointment.
Patients are responsible for addressing questions about their care to their provider and ensure understanding of their care and their role in the treatment process.
Patients are responsible for notifying their provider of any concerns regarding payment or insurance coverage.
You may be charged for missed appointments unless 24 hours notice is given.
___________________________________________________________________________
PATIENT SAFETY ISSUES
Take medications as prescribed by your doctor and do not alter medication dose or frequency without talking to your doctor.
Keep your medication locked in a medicine cabinet to keep away from your children to prevent any accidental overdose.
Do not drink alcoholic beverages, use illegal drugs, or use prescription medications not prescribed to you with your prescribed medications.
Do not drive a motor vehicle or operate machinery if your medication makes you sleepy, drowsy, or dizzy.
Do not give your medicines to anyone else for their use.
If you experience any adverse reactions or side effects, contact your doctor immediately.
If you develop a rash or dizziness stop taking medicine and contact your doctor immediately.
If you feel suicidal/homicidal contact 911 immediately, then contact your doctor.
HIPAA 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.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) 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” 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.
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information 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 would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. 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, 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 may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by Law, Public Health issues as required by law, Communicable Diseases, Health Oversight: Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation: Research, Criminal Activity, Military Activity and National Security, Worker’s Compensation. Inmates: 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.
Other permitted and required uses and disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Your rights
Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
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 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 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. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have your physician amend your protected health information. 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.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before November 29, 2010.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.
Patient Rights and Responsibilities
STATEMENT OF PATIENT RIGHTS
Patients have the right to be treated with dignity and respect.
Patients have the right to fair treatment regardless of race, religion, gender, ethnicity, age, disability, or source of payment.
Patients have the right to have their treatment and other information kept private.
Only in life-threatening situations or if required by law, can records be released without a signed consent from patients.
Patients have the right to information from staff/providers in a language they can understand.
Patients have the right to an easy to understand explanation of their condition and treatment.
Patients have the right to know all about their treatment choices regardless of cost coverage.
Patients have the right to get information about services offered by their providers and patient role in the treatment process.
Patients have the right to request professional information about their provider.
Patients have the right to know the clinical guidelines used in providing and/or managing their care.
Patients have the right to provide suggestions on office policies and procedure.
Patients have the right to complain and to know about the complaint, grievance, and appeals processes.
Patients have the right to know about State and Federal laws governing their rights and responsibilities.
Patients have the right to participate in the formation of their plan of care.
STATEMENT OF PATIENT RESPONSIBILITIES
If you miss two or more consecutive appointments without good reason and without informing our office, you will not be considered as an active patient with our system. We understand that you are terminating services with us - let us know if we can be of any help arranging alternative services for you.
Sign the medication consent forms to take medication prescribed by your psychiatrist.
In case of after-hours emergency, call 911. To reach your provider during regular business hours, please use the following number provided:
Office 8:30am – 5:00pm, Monday-Friday (804) 955-0965
Patients are responsible for providing their medical provider with accurate information needed to deliver quality care.
Patients are responsible for informing their provider when/if their treatment plan is no longer effective.
Patients are responsible to follow their treatment plans and to inform their provider of any changes to the treatment plan made by other providers including any changes in their medications.
Patients are responsible for reviewing their care and treatment plans continuously and reporting effectiveness or ineffectiveness of the care plan to their provider.
Patients are responsible for treating those giving them care with dignity and respect.
Patients should not be involved in any conscious behavior that could harm the lives of their provider, office staff, or other patients.
Patients are responsible for keeping their appointments, arriving on time, and notifying the office of any cancellation at least 24 hours prior to the appointment.
Patients are responsible for addressing questions about their care to their provider and ensure understanding of their care and their role in the treatment process.
Patients are responsible for notifying their provider of any concerns regarding payment or insurance coverage.
You may be charged for missed appointments unless 24 hours notice is given.
___________________________________________________________________________
PATIENT SAFETY ISSUES
Take medications as prescribed by your doctor and do not alter medication dose or frequency without talking to your doctor.
Keep your medication locked in a medicine cabinet to keep away from your children to prevent any accidental overdose.
Do not drink alcoholic beverages, use illegal drugs, or use prescription medications not prescribed to you with your prescribed medications.
Do not drive a motor vehicle or operate machinery if your medication makes you sleepy, drowsy, or dizzy.
Do not give your medicines to anyone else for their use.
If you experience any adverse reactions or side effects, contact your doctor immediately.
If you develop a rash or dizziness stop taking medicine and contact your doctor immediately.
If you feel suicidal/homicidal contact 911 immediately, then contact your doctor.