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, please contact a patient representative or the Longmont Clinic privacy official at the address or phone number listed at the bottom of this form.
Who will follow this notice?Longmont Clinic provides health care to our patients through our physicians, physician extenders, nurses and radiology, laboratory, and support staff. The Privacy Practices in this notice will be followed by:
- Any health care professional who treats you at any of our locations.
- All departments and units of our organization, including laboratory, radiology and all other departments at all Longmont Clinic locations.
- All employed associates or volunteers at any of our locations.
- Any business association or partner with whom we share health information.
Our pledge to you.
We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care that we maintain, whether created by facility staff, your doctor, or acquired from another health care provider. We are required by law to:
- Keep medical information about you private.
- Give you this notice of our legal duties and Privacy Practices with respect to medical information about you.
- Follow the terms of the notice that is currently in effect.
Changes to this Notice.
We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. Before we make a significant change in our policies, we will change our Notice of Privacy Practices and post the new notice in our lobbies and on our Web site (longmontclinic.com). You can receive a copy of the current notice at any time. The effective date is listed just below the title. You will be asked to acknowledge in writing your receipt of this notice.How we may use and disclose medical information about you.
- We may use and disclose medical information about you for treatment (such as sending medical information about you to a specialist as part of a referral or to an outside laboratory for processing); to obtain payment for treatment (such as an insurance company, third party payer, Medicare or other entity, or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record which are necessary for payment of your account. For example, a bill sent to a third party payer may include information that identifies you, your diagnosis and the procedures and supplies used. We may also provide payment information to other care providers who have been involved in your care, e.g., an oxygen supply company; and to support our health care operations (such as comparing patient data to improve treatment methods.)
- We may use or disclose medical information about you without your prior authorization during routine healthcare operations, including quality assurance, utilization review, medical review, internal auditing, accreditation, certification, licensing or credentialing activities of Longmont Clinic, medical research and educational purposes. Subject to certain requirements, we may give out medical information without prior authorization for public health purposes, abuse or neglect reporting, health oversight audits or inspections, research studies, funeral arrangements and organ donation, worker's compensation purposes and emergencies. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders.
- We also may contact you for appointment reminders or to tell you about or recommend possible treatment options, alternatives, health-related benefits or services that may be of interest to you.
- We may disclose medical information about you to doctors not affiliated with Longmont Clinic, if that doctor(s) provides on-call coverage for our doctors in order to insure continuity of care, or if some area of your care is being referred to an outside provider.
- Our waiting areas are shared and your name will be called when the doctor is ready for your appointment. If you object to this manner of notification, please tell us.
- Some of our treatment areas are shared and there will be other patients and family members in the same area where you are being treated. If you object to this manner of treatment, please tell us.
- We may disclose medical information about you, on your behalf, to a family member or friend or other caregiver who is involved in your medical care, to someone who helps pay for your care or to disaster relief authorities so that your family can be notified of your location and condition. If you have any objection to the use and disclosure of your health information in this manner, please tell us.
- We use family billing on our accounts and statements, all members of your family will be included on one account and one statement. If you object to this format of billing, please tell us.
- Longmont Clinic may engage outside companies to carry out certain aspects of routine healthcare operations. These entities are called the "business associates" of Longmont Clinic. Longmont Clinic may need to disclose your health information to the business associates to allow them to perform their duties. The business associates will, in turn, use and disclose your health information as they conduct business on Longmont Clinic's behalf. Examples of business associates include, but are not limited to, medical transcriptionists, consultants, accountants, lawyers, third party billing companies, and shredding companies. Longmont Clinic requires the business associate to protect the confidentiality of your health information.
Other uses of medical information.
- Uses and Disclosures Requiring Your Authorization: Longmont Clinic may not disclose your health information to persons outside of Longmont Clinic for purposes other than treatment, payment or healthcare operations without your authorization. In addition, Longmont Clinic may not use or disclose psychotherapy notes written by your mental health provider, if any, without your authorization, even for treatment, payment or healthcare operations. You have the right to revoke any authorization you have previously given by submitting a written statement of revocation to Longmont Clinic.
Uses and Disclosures that are required or permitted without consent or authorization.
Under certain circumstances, Longmont Clinic may use and disclose your health information to approved clinical research studies. While most clinical research studies require specific patient consent, there are some instances where a retrospective record review with no patient contact may be conducted by such researchers. For example, the research project may involve comparing the health and recovery of patients who received one medication for their medical condition to those who received a different medication for that same condition.
Longmont Clinic may disclose your health information to government and certain private health oversight agencies, e.g., the Department of Public Health and Environment, or the Board of Medical examiners, for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations and inspections. These activities are necessary to monitor compliance with the requirement of government programs.
Longmont Clinic may disclose your health information for law enforcement purposes as required by law or in response to a court order.
As required by law, Longmont Clinic may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, Longmont Clinic is required to report the existence of a communicable disease, such as acquired immune deficiency syndrome ("AIDS"), to the Department of Public Heath and Environment to protect the health and well-being of the general public.
Longmont Clinic may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Longmont Clinic may disclose your health information as required by military command authorities, if you are a member of the armed forces.
Your rights regarding medical information about you.
Although all records concerning your treatment obtained at Longmont Clinic are the property of Longmont Clinic, you have the following rights concerning your health information:
- In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care, when you submit a written request. A form for this purpose may be obtained at any registration desk or by calling the telephone number listed at the bottom of this form. If you request copies, we may charge a fee for the cost of copying, mailing or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.
- If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the records by submitting a request in writing that provides your reason for requesting the amendment. We may deny your request to amend a record if the information was not created by us; if it is not part of the medical information maintained by us; of if we determine that record is accurate. You may appeal a decision by us not to amend a record. Such appeals must be in written form.
- You have the right to a list of those instances where we have disclosed medical information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003. A form for this purpose may be obtained at any registration desk or by calling the telephone number listed at the bottom of this form. The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before you incur any costs.
- You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home. You may request this by notifying us in writing of the specific way or location for us to use to communicate with you.
- You may request, in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request but we are not legally required to accept it. We will inform you of our decision on your request.
All written requests or appeals should be submitted to our privacy office listed at the bottom of this notice.
Complaints and Concerns.
- If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our privacy office (listed below). You may also contact Longmont Clinic Administration at 720-494-3173.
- Finally, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our privacy office can provide you the address.
- Under no circumstance will you be penalized or retaliated against for filing a complaint or concern.
Privacy office information.
To contact Longmont Clinic privacy office, you may telephone 303-776-1234 and ask to be connected to that office, or you may write to:
Attention Privacy Official
1925 Mountain View Avenue
Longmont, Colorado 80501
Effective Date: April 14, 2003