Your Infor­ma­tion. Your Rights. Our Responsibilities

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.

Your Rights

When it comes to your health infor­ma­tion, you have cer­tain rights. This sec­tion explains your rights and some of our respon­si­bil­i­ties to help you.

Get an elec­tron­ic or paper copy of your med­ical record

• You can ask to see or get an elec­tron­ic or paper copy of your med­ical record and oth­er health infor­ma­tion we have about you. Ask us how to do this.
• We will pro­vide a copy or a sum­ma­ry of your health infor­ma­tion, usu­al­ly with­in 30 days of your request. We may charge a rea­son­able, cost-based fee.

• You can ask us to cor­rect health infor­ma­tion about you that you think is incor­rect or incom­plete. Ask us how to do this.
• We may say ​“no” to your request, but we’ll tell you why in writ­ing with­in 60 days.

Request con­fi­den­tial com­mu­ni­ca­tions
 

• You can ask us to con­tact you in a spe­cif­ic way (for exam­ple, home or office phone) or to send mail to a dif­fer­ent address.
• We will say ​“yes” to all rea­son­able requests.

Ask us to lim­it what we use or share

• You can ask us not to use or share cer­tain health infor­ma­tion for treat­ment, pay­ment, or our oper­a­tions. We are not required to agree to your request, and we may say ​“no” if it would affect your care.
• If you pay for a ser­vice or health care item out-of-pock­et in full, you can ask us not to share that infor­ma­tion for the pur­pose of pay­ment or our oper­a­tions with your health insur­er. We will say ​“yes” unless a law requires us to share that information.
• As part of our ongo­ing efforts to pro­vide qual­i­ty care to our patients, The South Bend Clin­ic par­tic­i­pates in var­i­ous elec­tron­ic health infor­ma­tion exchanges (HIE). This activ­i­ty allows your med­ical infor­ma­tion to be read­i­ly avail­able to oth­er com­mu­ni­ty health­care providers for coor­di­na­tion of care and may avoid dupli­cate test­ing.
   

Get a list of those with whom we’ve shared information

• You can ask for a list (account­ing) of the times we’ve shared your health infor­ma­tion for six years pri­or to the date you ask, who we shared it with, and why.
• We will include all the dis­clo­sures except for those about treat­ment, pay­ment, and health care oper­a­tions, and cer­tain oth­er dis­clo­sures (such as any you asked us to make). We’ll pro­vide one account­ing a year for free but will charge a rea­son­able, cost-based fee if you ask for anoth­er one with­in 12 months.

Get a copy of this pri­va­cy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice elec­tron­i­cal­ly. We will pro­vide you with a paper copy prompt­ly. Pri­va­cy Notice Document

Choose some­one to act for you

• If you have giv­en some­one med­ical pow­er of attor­ney or if some­one is your legal guardian, that per­son can exer­cise your rights and make choic­es about your health information.
• We will make sure the per­son has this author­i­ty and can act for you before we take any action.

File a com­plaint if you feel your rights are vio­lat­ed
 

• You can com­plain if you feel we have vio­lat­ed your rights by con­tact­ing us using the infor­ma­tion at the bot­tom of this poster.
• You can file a com­plaint with the U.S. Depart­ment of Health and Human Ser­vices Office for Civ­il Rights by send­ing a let­ter to 200 Inde­pen­dence Avenue, S.W., Wash­ing­ton, D.C. 20201, call­ing 1−877−696−6775, or vis­it­ing www​.hhs​.gov/​o​c​r​/​p​r​i​v​a​c​y​/​h​i​p​a​a​/​c​o​m​p​l​a​ints/
• We will not retal­i­ate against you for fil­ing a complaint.

Your Choic­es

For cer­tain health infor­ma­tion, you can tell us your choic­es about what we share. If you have a clear pref­er­ence for how we share your infor­ma­tion in the sit­u­a­tions described below, talk to us. Tell us what you want us to do, and we will fol­low your instruc­tions.

In these cas­es, you have both the right and choice to tell us to:

• Share infor­ma­tion with your fam­i­ly, close friends, or oth­ers involved in your care
• Share infor­ma­tion in a dis­as­ter relief situation
• Include your infor­ma­tion in a hos­pi­tal directory
• Con­tact you for fundrais­ing efforts

If you are not able to tell us your pref­er­ence, for exam­ple if you are uncon­scious, we may go ahead and share your infor­ma­tion if we believe it is in your best inter­est. We may also share your infor­ma­tion when need­ed to lessen a seri­ous and immi­nent threat to health or safe­ty.

In these cas­es, we nev­er share your infor­ma­tion unless you give us writ­ten permission:

• Mar­ket­ing purposes
• Sale of your information
• Most shar­ing of psy­chother­a­py notes

In the case of fundraising:

• We may con­tact you for fundrais­ing efforts, but you can tell us not to con­tact you again.

Our Uses and Disclosures

How do we typ­i­cal­ly use or share your health infor­ma­tion? We typ­i­cal­ly use or share your health infor­ma­tion in the fol­low­ing ways.

Treat you

• We can use your health infor­ma­tion and share it with oth­er pro­fes­sion­als who are treat­ing you.
  Exam­ple: A doc­tor treat­ing you for an injury asks anoth­er doc­tor about your over­all health condition.

Run our organization

• We can use and share your health infor­ma­tion to run our prac­tice, improve your care, and con­tact you when nec­es­sary.
  Exam­ple: We use health infor­ma­tion about you to man­age your treat­ment and ser­vices.
   

Bill for your ser­vices
 

• We can use and share your health infor­ma­tion to bill and get pay­ment from health plans or oth­er enti­ties.
  Exam­ple: We give infor­ma­tion about you to your health insur­ance plan so it will pay for your services.

How else can we use or share your health infor­ma­tion? We are allowed or required to share your infor­ma­tion in oth­er ways — usu­al­ly in ways that con­tribute to the pub­lic good, such as pub­lic health and research. We have to meet many con­di­tions in the law before we can share your infor­ma­tion for these pur­pos­es. For more infor­ma­tion see: www​.hhs​.gov/​o​c​r​/​p​r​i​v​a​c​y​/​h​i​p​a​a​/​u​n​d​e​r​s​t​a​n​d​i​n​g​/​c​o​n​s​u​m​e​r​s​/​i​n​d​e​x​.html

Help with pub­lic health and safe­ty issues
 

We can share health infor­ma­tion about you for cer­tain sit­u­a­tions such as:

• Pre­vent­ing disease
• Help­ing with prod­uct recalls
• Report­ing adverse reac­tions to medications
• Report­ing sus­pect­ed abuse, neglect, or domes­tic violence
• Pre­vent­ing or reduc­ing a seri­ous threat to any­one’s health or safety

Do research

• We can use or share your infor­ma­tion for health research.

Com­ply with the law
 

• We will share infor­ma­tion about you if state or fed­er­al laws require it, includ­ing with the Depart­ment of Health and Human Ser­vices if it wants to see that we’re com­ply­ing with fed­er­al pri­va­cy law.

Respond to organ and tis­sue dona­tion requests

• We can share health infor­ma­tion about you with organ pro­cure­ment organizations.

Work with a med­ical exam­in­er or funer­al director

• We can share health infor­ma­tion with a coro­ner, med­ical exam­in­er, or funer­al direc­tor when an indi­vid­ual dies.

Address work­ers’ com­pen­sa­tion, law enforce­ment, and oth­er gov­ern­ment requests
We can use or share health infor­ma­tion about you:
 

• For work­ers’ com­pen­sa­tion claims
• For law enforce­ment pur­pos­es or with a law enforce­ment official
• With health over­sight agen­cies for activ­i­ties autho­rized by law
• For spe­cial gov­ern­ment func­tions such as mil­i­tary, nation­al secu­ri­ty, and pres­i­den­tial pro­tec­tive ser­vices
  
   

Respond to law­suits and legal actions
 

• We can share health infor­ma­tion about you in response to a court or admin­is­tra­tive order, or in response to a subpoena.

Our Respon­si­bil­i­ties

• We are required by law to main­tain the pri­va­cy and secu­ri­ty of your pro­tect­ed health information.
• We will let you know prompt­ly if a breach occurs that may have com­pro­mised the pri­va­cy or secu­ri­ty of your information.
• We must fol­low the duties and pri­va­cy prac­tices described in this notice and give you a copy of it.
• We will not use or share your infor­ma­tion oth­er than as described here unless you tell us we can in writ­ing. If you tell us we can, you may change your mind at any time. Let us know in writ­ing if you change your mind.

For more infor­ma­tion see: www​.hhs​.gov/​o​c​r​/​p​r​i​v​a​c​y​/​h​i​p​a​a​/​u​n​d​e​r​s​t​a​n​d​i​n​g​/​c​o​n​s​u​m​e​r​s​/​n​o​t​i​c​e​p​p​.html

Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all infor­ma­tion we have about you. The new notice will be avail­able upon request, in our office, and on our web site. This notice applies to The South Bend Clin­ic and all depart­ments, units, sites, and loca­tions of The South Bend Clinic.