Notice of Privacy PracticesIMPORTANT: 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.
As an essential part of our commitment to you, Delcrest Medical Services, Inc, (herein known as DMS) maintains the privacy of certain confidential health care information about you, known as Protected Health Information or PHI. We are required by law to protect your health care information and to provide you with the attached Notice of Privacy Practices.
The Notice outlines our legal duties and privacy practices with respect to your PHI. It not only describes our privacy practices and your legal rights, but lets you know, among other things, how DMS is permitted to use and disclose PHI about you, how you can access and copy that information, how you may request restrictions on our use and disclosure of your PHI.
DMS is also required to abide by the terms of the version of this Notice currently in effect. In most situations we may use this information as described in this notice without your permission, but there are some situations where we may use it only after we obtain you written authorization, if we are required by law to do so.
We respect your privacy, and treat all health care information about our patients with care under strict policies of confidentiality that all of our staff is committed to following at all times.
PLEASE READ THE ATTACHED DETAILED NOTICE. IF YOU HAVE ANY QUESTIONS ABOUT IT, PLEASE CONTACT SCOTT SEIZ OUR PRIVACY OFFICER AT 215-675-4444.
Patient Rights
As a patient, you have a number of rights with respect to the protection of your PHI, including:The right to access copy or inspect your PHI. This means you may come to our offices and inspect and copy most of the medical information about you that we maintain. We will normally provide you with access to this information within 30 days of your request. We may also charge you a reasonable fee to copy any medical information that you have the right to access. In limited circumstances, we may deny you access to your medical information, and you may appeal certain types of denials.
We have available forms to request access to your PHI and we will provide a written response if we deny you access and let you know your appeal rights. If you wish to inspect and copy your medical information, you should contact the privacy officer at the end of this notice.
The right to amend your PHI. You have the right to ask us to amend medical information that we may have about you. We will generally amend your information within 60 days of your request and will notify you when we have amended the information. We are permitted by law to deny your request to amend your medical information you have asked us to amend is correct. If you wish to request that we amend the medical information that we have about you, you should contact the privacy officer listed at the end of this notice.
The right to request and accounting of our use and disclosure of your PHI. You may request and accounting from us of certain disclosures of your medical information that we have made in the last six years prior to the date of your request. We are not required to give you an accounting of information we have used or disclosed for purposes of treatment, payment or health care operations, or when we share your health information with our business associates, like our billing company or a medical facility from/to which we have transported you.
We are also not required to give you an accounting of our uses of protected health information for which you have already given us written authorization. If you wish to request and accounting of the medical information about you that we have used or disclosed that is not exempt from the accounting requirement, you should contact the privacy officer listed at the end of this notice.
The right to request that we restrict the uses and disclosures of your PHI. You have the right to request that we restrict how we use and disclose your medical information that we have about you for treatment, payment or health care operations, or to restrict the information that is provided to family, friends and other individuals involved in our health care. But if you request a restriction and the information you asked us to restrict is needed to provide you with emergency treatment, than we may use the PHI or disclose the PHI to a health care provider to provide you with emergency treatment. DMS is not required to agree to any restrictions you request.
Internet, Electronic Mail, and the right to obtain copy of paper Notice on request:
This notice is posted on our web site (www.delcrest.com); you can print a copy of this notice or request a copy to be sent electronically. If you allow us, we will forward you this notice by electronic mail instead of on paper and you may always request a paper copy of the notice.Revisions to the Notice:
DMS reserves the right to change the terms of this notice at any time, and the changes will be effective immediately and will apply to all protected health information that we maintain. Any material changes to the notice will be promptly posted in our facilities and posted to our web site, if we maintain one. You can get a copy of the latest version of this notice by contacting the Privacy Officer identified below.Your Legal Right and Complaints:
You also have the right to complain to us, or to the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against in any way for filing a complaint with us or to the government. Should you have any questions, comments or complaints you may direct all inquiries to the privacy officer listed at the end of this notice.If you have any questions or wish to file a complaint or exercise any rights listed in this notice, please contact:
Scott Seiz
Privacy Officer
Delcrest Medical Services
100 Commerce Drive
Ivyland, Pa. 18974
215-675-4444Effective Date of the Notice: April 14, 2003
Name: ___________________________________________________________________
Acknowledgement
I certify that I received a copy of Delcrest Medical Services Privacy Notice and that I have had an opportunity to review this document and ask questions to assist me in understanding my rights relative to the protection of my health information. I am satisfied with the explanations provided to me and I am confident that Delcrest Medical Services is committed to protecting my health information.
Date:_____________ My Signature: __________________________________________________
My Printed Name: _________________________________________________
Date:_____________ Signature of Witness: ________________________________________________
-OR-I certify that I am the authorized representative of ___________________________________________, and that I have received the Privacy Notice on behalf of this individual and that Delcrest Medical Services provided me with an opportunity to review this document and ask questions to assist me in understanding his/her privacy rights. I am satisfied with the explanations provided to me and I am confident that Delcrest Medical Services is committed to protecting health information.
Date:______________ Signature of Representative: _______________________________________
Printed Name: _______________________________________
Relationship to Individual: _______________________________________Date:______________ Signature of Witness: ______________________________________
A copy of this document must be provided to the person to whom the Privacy Notice was provided and a copy must be filed in the medical record.