HIPAA NOTICE OF PRIVACY PRACTICES 

NOTICE OF INFORMATION PRACTICES 

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN ACCESS TO SUCH INFORMATION.  PLEASE REVIEW THIS NOTICE CAREFULLY. 

Each time you visit a hospital, physician, or other health care provider, including a dialysis facility, a record of your visit is made.  These records typically contain information regarding your symptoms, examination and test results, diagnoses, treatment, and care plan. This information, which may be referred to as your continuous medical record or health record, may be used: 

1. As a basis for planning your care and treatment. 

2. To coordinate your health care with the other health professionals who contribute to your care. 

3. To process insurance claims and to allow third party payers to verify that the services billed were provided. 

4. As a tool in educating health care professionals and as a source of data for medical research. 

5. As a source of information for public health officials. 

6. As a source of data for facility planning and marketing. 

7. As a tool for quality assurance and continuous quality improvement. 

8. As required by federal and state laws and regulations. 

YOUR HEALTH INFORMATION RIGHTS 

You have the right to: 

1. Request restrictions on the use and disclosure of your health information.  However, the Facility is not required to agree to the restriction. 

2. Inspect and copy all or any part of your medical or health record, as provided by 45 C.F.R. §164.524. 

3. Amend your health record, as provided by 45 C.F.R. §164.526. 

4. Request and receive an accounting of disclosures made of your health information, except for disclosures made for the purpose of treatment, payment, health care operations and certain other purposes, as set forth in 45 C.F.R. §164.528. 

5. Obtain a paper copy of this Notice from the Facility upon request. 

6. Review this Notice before executing consent to the use and disclosure of your health information for payment, treatment, or health care operations. 

7. Receive communications of your health information by alternative means or at alternative locations, i.e., a different address. 

8. Revoke your consent to the use and disclosure of your health information, except to the extent that action has already been taken in reliance thereon. 

 FACILITY’S RESPONSIBILITIES 

1.   Maintain the privacy of your health information. 

2. Provide you with notice as to our legal duties and privacy practices with respect to the information we maintain and collect about you. 

3. Abide by the terms of this Notice. 

4. Notify you if we are unable to agree to a requested restriction. 

5. Provide you with a revised copy of this Notice if it is altered or amended. 

We reserve the right to change the terms of this Notice and to make the new notice provisions effective for all health information that we maintain.  We will send you a copy of the revised notice, by mail, to the address that you provide to us. 

We will not use or disclose your personal health information in a manner inconsistent with this notice without your consent or authorization. 

FOR MORE INFORMATION OR TO REPORT A PROBLEM 

If you have questions or would like additional information, you may contact the facility’s contact person, the Charge Nurse, or the facility’s administrator.  If you believe your privacy rights have been violated, you may file a complaint with the privacy official.  Additionally, you may file a complaint with the Secretary of the Department of Health and Human Services, Office of Civil Rights at (800) 368-1019.  There will be no retaliation against you for filing a complaint.   

EXAMPLES OF DISCLOSURES FOR PAYMENT, TREATMENT AND HEALTH CARE OPERATIONS  

We will use your health information for treatment. 

For example: Information obtained by your nephrologist, by a nurse, or by another member of your health care team will be recorded in your health record and used to develop a treatment plan for you.  Your physician will order a course of dialysis treatment for you.  Members of your health care team, including nurses and technicians, will record details of your dialysis treatments, along with any observations about your health status before, during and after the dialysis treatment.  This information will be reviewed by your physician and other members of your health care team as needed. 

We will use your health information for payment. 

For example: A bill may be sent to you or to a third-party payer.  The information on the bill or accompanying the bill may include information that identifies you, your diagnosis, the treatment rendered to you, and the supplies and equipment used to perform the procedures. 

We will use your health information for regular health care operations. 

For example: Employees of the Facility and its medical staff may use information in your health record to assess the quality of the care and treatment you receive here, and outcomes in your case and others like it.  The information will then be used to continually improve the quality and effectiveness of the health care and services that we provide to all our patients. 

EXAMPLES OF OTHER PERMISSIBLE OR REQUIRED DISCLOSURES 

Business associates: There are some services provided at this facility or on behalf of Lakes Dialysis Center, Inc. through contracts with business associates.  Examples include medical director services provided by physicians with whom we have contracted, training services provided by manufacturers of dialyzers and other medical equipment, and legal and consulting services provided in response to billing and reimbursement issues which may arise from time to time.  When we enter contracts to obtain these services, we may need to disclose your health information to our business associate so that the associate may perform the job that we have requested.  To protect your health information, however, we require our business associate to appropriately safeguard your information. 

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or other person responsible for your care of your location and general condition. 

Communication with family members:  Health professionals, including those employed by or under contract with the Facility, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relative to that person’s involvement in your care or payment related to your care. 

Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. 

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

Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. 

Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. 

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public. 

Effective Date of Notice July 1, 2011