Effective Date: March 6, 2014
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
If you have any questions about this notice, please contact us:
11995 Singletree Lane N Suite 120
Eden Prairie, MN 55344
FOR INFORMATION REGARDING HOW ORTHOLOGY AFFILIATED PRACTICES USE MEDICAL INFORMATION ABOUT YOU, HOW THIS INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE CONTACT THE ORTHOLOGY AFFILIATED PRACTICE FROM WHICH YOU RECEIVED SERVICE.
1. Summary of Rights and Obligations Concerning Health Information
Orthology is committed to preserving the privacy and confidentiality of your health information, which is required both by federal and state law, as well as by ethics of the medical profession. We are required by law to provide you with this notice of our legal duties, your rights, and our privacy practices, with respect to using and disclosing your health information that is created or retained by Orthology.
Each time you visit us, we make a record of your visit. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. We have an ethical and legal obligation to protect the privacy of your health information, and we will only use or disclose this information in limited circumstances. In general and subject to your acknowledgement of receipt of this Notice of Privacy Practices or our documented good faith attempt at obtaining your acknowledgment, we may use and disclose your health information without your express written authorization to:
We may also use or disclose your health information where you have authorized us to do so.
You have certain rights to your health information. You have the right to:
We are required to:
We reserve the right to change our practices and to make the new provisions effective for all your health information that we maintain.
Should our information practices change, a revised Notice of Privacy Practices will be available upon request. If there is a material change, a revised Notice of Privacy Practices will be distributed to the extent required by law.
We will not use or disclose your health information without your authorization, except as described in our most current Notice of Privacy Practices.
In the following pages, we explain our privacy practices and your rights to your health information in more detail.
2. We May Use or Disclose Your Medical Information Without Your Express Written Authorization In The Following Ways
3. Authorization for Other Uses of Medical Information
Uses of medical information not covered by our most current Notice of Privacy Practices or the laws that apply to us will be made only with your written authorization.
If you provide us with authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except to the extent that we have already taken action in reliance on your authorization or, if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has the right to contest a claim or the insurance coverage itself. We are unable to take back any disclosures we have already made with your authorization, and we are required to retain our records of the care that we provided to you.
4. Your Health Information Rights
You have the following rights regarding medical information we gather about you:
If we deny your request for amendment, you may submit a statement of disagreement.
We may reasonably limit the length of this statement. Your letter of disagreement will be included in your medical record, but we may also include a rebuttal statement.
To request an accounting of disclosures, you must submit your request in writing to our privacy officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you would like the accounting of disclosures (for example, on paper or electronically by e-mail). The first accounting of disclosures you request within any 12 month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting of disclosures. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time, before any costs are incurred. Under limited circumstances mandated by federal and state law, we may temporarily deny your request for an accounting of disclosures.
In the event the breach involves 10 or more patients whose contact information is out of date we will post a notice of the breach on the home page of our Web site or in a major print or broadcast media. If the breach involves more than 500 patients in the state or jurisdiction, we will send notices to prominent media outlets. If the breach involves more than 500 patients, we are required to immediately notify the Secretary. We also are required to submit an annual report to the Secretary of a breach that involved less than 500 patients during the year and will maintain a written log of breaches involving less than 500 patients.
You may contact Orthology’s Privacy Officer by US Mail at the following address:
11995 Singletree Lane N #120
Eden Prairie, MN 55344
Or by electronic mail at the following e-mail address: email@example.com