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.

Boulder Medical Center is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Your Personal Health Information

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. Your personal health information that is protected by law broadly includes any information, oral, written or recorded, that is created or received by certain health care entities, including health care providers, such as physicians and hospitals, as well as, health insurance companies or plans. The law specifically protects health information that contains data, such as your name, address, social security number, and others, that could be used to identify you as the individual patient who is associated with that health information.

Disclosure of Your Health Care Information

Without Your Consent

Without your consent, we may use or disclose your personal health information in order to provide you with services and the treatment you require or request, or to collect payment for those services, and to conduct other related health care operations otherwise permitted or required by law.  Also, we are permitted to disclose your personal health information within and among our workforce in order to accomplish these same purposes.   However, even with your permission, we are still required to limit such uses or disclosures to the minimal amount of personal health information that is reasonably required to provide those services or complete those activities.

Treatment

We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.

For example:

“On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with Boulder Medical Center, P.C.”

“It is our policy to provide a substitute health care provider, authorized by Boulder Medical Center, P.C. to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation.”

Payment

We may disclose your health information to your insurance provider for the purpose of payment or health care operations.
For example:

“As a courtesy to our patients, we will submit an itemized billing statement to those insurance carriers with whom we have a contract for the purpose of payment to Boulder Medical Center for health care services rendered.  If you pay for your health care services personally or if we are not contracted with your insurance carrier, we will, as a courtesy, provide an itemized billing to you for the purpose of reimbursement from your insurance carrier. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes that describe the health care services received.”

Health care operations

Other examples of disclosure of your health information for health care operations are

“for the purpose of contacting patients with information about treatment alternatives or communications in connection with care management or care coordination; for medical review, legal services, and auditing functions; and for general administrative activities such as customer service and data analysis.”

As Required By Law

Examples of instances in which we are required to disclose your personal health information include:

Work related illness or injury

We may disclose your health information as necessary to evaluate whether you have a work-related illness or injury in order to comply with Federal or state law.

Emergencies

We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.

Public Health  

As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.

Judicial and Administrative Proceedings

We may disclose your health information in the course of judicial and administrative proceedings in response to an order of a court or administrative tribunal, a warrant, subpoena, discovery request, or other lawful process.

Law Enforcement

We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.

Deceased Persons

We may disclose your health information to coroners or medical examiners.

Health Care Oversight Activities

We may disclose your health information for health oversight activities including, audits, civil, administrative, or criminal investigations, inspections, licensure or disciplinary actions, or civil, administrative, or criminal proceedings or actions, or other activities necessary for appropriate oversight of government benefit programs.

Organ Donation

We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.

Research

We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.

Public Safety

It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public, for example, disclosures regarding victims of abuse, neglect, or domestic violence including, reporting to social service or protective services agencies

Specialized Government Agencies

We may disclose your health information for military and veterans activities;national security and intelligence activities, protective services of the President and others; medical suitability determinations by entities that are components of the Department of State and government benefits purposes.

All Other Situations, With Your Specific Authorization

Except as otherwise permitted or required, as described above, we may not use or disclose your personal health information without your written authorization.  Further, we are required to use or disclose your personal health information consistent with the terms of your authorization.  You may revoke your authorization to use or disclose any personal health information at any time, except to the extent that we have taken action in reliance on such authorization, or, if you provided the authorization as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy.

Miscellaneous Activities Notice

Marketing

We may contact you for marketing purposes, as described below:

We may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.  

“As a courtesy to our patients, it is our policy to call your home one to two evenings prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment and the doctor name or area along with a request to call our office if you need to cancel or reschedule your appointment.”

Change of Ownership

In the event that Boulder Medical Center, P.C. is sold or merged with another organization, your health information/record will become the property of the new owner.

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you.

  • You have the right to request restrictions on certain uses and disclosures of your health information. You may request restrictions on the following uses or disclosures: (a) to carry out treatment, payment, or healthcare operations; (b) disclosures to family members, relatives, or close personal friends of personal health information directly relevant to your care or payment related to your health care, or your location, general condition, or death; (c) instances in which you are not present or your permission cannot practicably be obtained due to your incapacity or an emergency circumstance; (d) permitting other persons to act on your behalf to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of personal health information; or (e) disclosure to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.  Please be advised, however, that Boulder Medical Center, P.C. is not required to agree to the restriction that you requested.
  • You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. This includes an electronic copy of your electronic PHI. We may condition the provision of confidential communications on you providing us with information as to how payment will be handled and specification of an alternative address or other method of contact.  We may require that a request contain a statement that disclosure of all or a part of the information to which the request pertains could endanger you.  We may not require you to provide an explanation of the basis for your request as a condition of providing communications to you on a confidential basis. We must permit you to request and must accommodate reasonable requests by you to receive communications of personal health information from us by alternative means or at alternative locations.
  • You have the right of access to inspect and obtain a copy of your health information, except for (a) psychotherapy notes, (b) information complied in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding, and (c) health information maintained by us to the extent to which the provision of access to you would be prohibited by law. We may require written requests. If you request a copy of your personal health information or agree to a summary or explanation of such information, we may charge a reasonable cost-based fee for copying, postage, if you request a mailing, and the costs of preparing an explanation or summary as agreed upon in advance.
  • You have a right to request that Boulder Medical Center, P.C. amend your protected health information. We have the right to deny your request for amendment, if: (a) we determine that the information or record that is the subject of the request was not created by us, unless you provide a reasonable basis to believe that the originator of the information is no longer available to act on the requested amendment, (b) the information is not part of your designated record set maintained by us, (c) the information is prohibited from inspection by law, or (d) the information is accurate and complete.  We may require that you submit written requests and provide a reason to support the requested amendment.  If we deny your request, we will provide you with a written denial stating the basis of the denial, your right to submit a written statement disagreeing with the denial, and a description of how you may file a complaint with us or the Secretary of the U.S. Department of Health and Human Services (“DHHS”).  This denial will also include a notice that if you do not submit a statement of disagreement, you may request that we include your request for amendment and the denial with any future disclosures of your personal health information that is the subject of the requested amendment.  Copies of all requests, denials, and statements of disagreement will be included in your designated record set.  If we accept your request for amendment, we will make reasonable efforts to inform and provide the amendment within a reasonable time to persons identified by you as having received personal health information of yours prior to amendment and persons that we know have the personal health information that is the subject of the amendment and that may have relied, or could foreseeably rely, on such information to your detriment.  All requests for amendment shall be sent to Release of Records, Boulder Medical Center, 2750 Broadway, Boulder, Colorado 80304.
  • You have a right to receive an accounting of disclosures of your protected health information made by Boulder Medical Center, P.C. We may require written requests. Beginning April 14, 2003, you have the right to receive a written accounting of all disclosures of your personal health information that we have made within the six (6) year period immediately preceding the date on which the accounting is requested.  You may request an accounting of disclosures for a period of time less than six (6) years from the date of the request. We are not required to provide accountings of disclosures for the following purposes: (a) treatment, payment, and healthcare operations, (b) disclosures pursuant to your authorization, (c) disclosures to you, (d) for a facility directory or to persons involved in your care, (e) for national security or intelligence purposes, (f) to correctional institutions, and (g) with respect to disclosures occurring prior to 4/14/03.  We reserve our right to temporarily suspend your right to receive an accounting of disclosures to health oversight agencies or law enforcement officials, as required by law.  We will provide the first accounting to you in any twelve (12) month period without charge, but will impose a reasonable cost-based fee for responding to each subsequent request for accounting within that same twelve (12) month period.  All requests for an accounting shall be sent to Release of Records, Boulder Medical Center, 2750 Broadway, Boulder, Colorado 80304.
  • You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
  • You have the right to request no information be shared with insurer if paid in full, out of pocket at the time of service.
  • You have the right to be notified of reportable breeches of privacy and security.

 

Changes to this Notice of Privacy Practices

Boulder Medical Center, P.C. reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Boulder Medical Center, P.C. is required by law to comply with this Notice.

Boulder Medical Center, P.C. is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information.  If you have questions about any part of this notice or if you want more information about your privacy rights, please contact the Director of Nursing by calling 303-440-3252. If the Director of Nursing is not available, you may make a future appointment for a personal conference in person or by telephone.

Complaints

Complaints about your Privacy rights, or how Boulder Medical Center, P.C. has handled your health information should be directed to the Patient Advocate by calling 303-440-3125. If the Patient Advocate is not available, you may make a future appointment for a personal conference in person or by telephone.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC  20201

This notice is effective as of April 14, 2003.

Revised 12/07

Revised 08/13

Revised 05/14

Revised 10/15

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