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 Your
Privacy is important to us. We take care to keep your
records confidential. You always have access to your
personal medical record. We have outlined below how
to access your medical record.
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NOTICE OF PRIVACY
PRACTICES FOR:
ESSEX COUNTY OB/GYN ASSOCIATES, INC.
Associates in OB/GYN a division of Essex County OB/GYN
Liberty Tree Physicians & Midwives a division
of Essex County OB/GYN
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
(TPO) 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 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 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;
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’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. The fee for copying your chart is$20.00 plus
$.25 per page and all mailing expenses.
You have the right to request a restriction of your protected
health information. 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 request. If the physician believes it is in your
best interests 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 Secetary 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 April
14, 2003.
Updates March 15, 2004.
Privacy Officer: Faye Doliber RN, MBA
Please mail or fax any written request to “Attention
Medical Records Department” at your Provider’s
Office.
Provider’s Office address
and Confidential fax numbers:
Associates in OB/GYN 83 Herrick Street, Suite 2004 Beverly,
MA 01915.
Medical records department Fax 978 232-5529.
Associates in OB/GYN – The Babson’s Women’s
Center 298 Washington Street, Gloucester MA 01930. Medical
records department Fax 978 232-5547.
Liberty Tree Physicians and Midwives 140 Commonwealth
Ave., Danvers, MA 01923. Medical records department fax
978 232-5729
Liberty Tree Physicians and Midwives 83 Herrick Street,
Suite 3002 Beverly, MA 01915. Medical records department
Fax 978 232-5717
Essex County OB/GYN 65 Central Street, Suite E, Georgetown
MA 01833. Medical records department FAX 978 232-5557. |
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