Summit Medical Group, PLLC (“Summit”) is permitted
by federal privacy laws to make uses and disclosures of your health information
for purposes of treatment, payment, and health care operations. Protected health information is the information
we create and obtain in providing our services to you. Such information may include documenting your
symptoms, examination and test results, diagnoses, treatment, and applying for
future care or treatment. It also
includes billing documents for those services.
uses of your health information for treatment purposes are:
· During the course of your treatment, the physician determines he/she
will need to consult with another specialist in the area. He/she will share the information with such
specialist and obtain his/her input.
Example of use
of your health information for payment purposes:
· We submit requests for payment to your health insurance company. The health insurance company or business
associate helping us obtain payment requests information from us regarding your
medical care given. We will provide
information to them about you and the care given.
Example of Use
of Your Information for Health Care Operations:
· We may obtain services from business
associates such as quality assessment, quality improvement, outcome evaluation,
protocol and clinical guidelines development, training programs, credentialing,
medical review, legal services, and insurance.
We will share information about you with such business associates as
necessary to obtain these services.
YOUR HEALTH INFORMATION
The health and billing records we maintain are the
physical property of Summit. You have
the following rights with respect to your Protected Health Information
- Request a restriction on certain uses and disclosures of your
health information by delivering the request in writing to our office—we
are not required to grant the request but we will comply with any request
- Obtain a paper copy of the Notice of Privacy Practices for
Protected Health Information ("Notice") by making a request at
- Right to inspect and copy your
health record and billing record—you may exercise this right by delivering
the request in writing to our office using the form we provide to you upon
request; appeal a denial of access to your protected health information
except in certain Circumstances;
- Right to request that your health care record be amended to
correct incomplete or incorrect information by delivering a written
request to our office using the form we provide to you upon request. (The physician or other health care
provider is not required to make such amendments); you may file a
statement of disagreement if your amendment is denied, and require that
the request for amendment and any denial be attached in all future
disclosures of your protected health information;
- Right to receive an accounting of
disclosures of your health information as required to be maintained by law
by delivering a written request to our office using the form we provide to
you upon request. An accounting
will not include internal uses of information for treatment, payment, or
operations, disclosures made to you or made at your request, or
disclosures made to family members or friends in the course of providing
- Right to confidential communication by requesting that communication of your health information be
made by alternative means or at an alternative location by delivering the
request in writing to our office using the form we give you upon request;
If you want to exercise any of the above rights,
please contact Summit’s Privacy Officer in
person or in writing, during normal hours.
He will provide you with assistance on the steps to take to exercise
is required to:
Maintain the privacy of your health information as required by law;
Provide you with a notice as to our duties and privacy practices as to
the information we collect and maintain about you;
Abide by the terms of this Notice;
Notify you if we cannot accommodate a requested restriction or request;
Accommodate your reasonable requests regarding methods to communicate
health information with you.
Accommodate your request for an accounting of disclosures.
Notify you in the event there is a breach of unsecured protected health
We reserve the right to amend, change, or eliminate
provisions in our privacy practices and access practices and to enact new
provisions regarding the protected health information we maintain. If our information practices change, we will
amend our Notice. You are entitled to
receive a revised copy of the Notice by calling and requesting a copy of our
“Notice” or by visiting our office and picking up a copy.
Request Information or File a Complaint
If you have questions, would like additional
information, or want to report a problem regarding the handling of your
information, you may contact:
Weisgarber Road, Suite N-200
We cannot, and will not, require you to waive the
right to file a complaint with the Secretary of Health and Human Services (HHS)
as a condition of receiving treatment from the office.
We cannot, and will not, retaliate against you for
filing a complaint with the Secretary of Health and Human Services.
IS A LIST OF OTHER USES AND DISCLOSURES ALLOWED BY THE PRIVACY RULE
We may contact you to provide you with appointment
reminders, with information about treatment alternatives, or with information
about other health-related benefits and services that may be of interest to
you. We may contact you as part of a fund raising effort.
Notification – Opportunity to Agree or Object
Unless you object we may use
or disclose your protected health information to notify, or assist in
notifying, a family member, personal representative, or other person
responsible for your care, about your location, and about your general
condition, or your death.
We may use and disclose your
protected health information to assist in disaster relief efforts.
Opportunity to Agree or Object Not Required
PUBLIC HEALTH ACTIVITIES
Disease - As
required by law, we may disclose your protected health information to public
health or legal authorities charged with preventing or controlling disease,
injury, or disability.
Child Abuse & Neglect - We may disclose protected
health information to public authorities as allowed by law to report child
abuse or neglect.
Food and Drug
Administration (FDA) - We may disclose to the FDA your protected health information relating
to adverse events with respect to food, supplements, products and product
defects, or post-marketing surveillance information to enable product recalls,
repairs, or replacements.
Employment Related – We may disclose to employers your protected health
information to the extent such information is related to medical surveillance
or evaluation of a work related injury or illness if the employer needs such
information to comply with OSHA rules and regulations.
VICTIMS OF ABUSE,
NEGLECT, OR DOMESTIC VIOLENCE
Federal law allows us to release your protected
health information to appropriate health oversight agencies or for health
oversight activities to include audits, civil, administrative or criminal
investigations: inspections; licensures or disciplinary actions, and for
similar reasons related to the administration of healthcare.
We may disclose your protected health information in
the course of any judicial or administrative proceeding as allowed or required
by law, with your consent, or as directed by a proper court order or
administrative tribunal, provided that only the protected health information
released is expressly authorized by such order, or in response to a subpoena,
discovery request or other lawful process.
We may disclose your protected health information
for law enforcement purposes as required by law, such as when required by court
order, including laws that require reporting of certain types of wounds or
other physical injury.
MEDICAL EXAMINERS AND FUNERAL DIRECTORS
We may disclose your protected health information to
funeral directors or coroners consistent with applicable law to allow them to
carry out their duties.
ORGAN PROCUREMENT ORGANIZATIONS
Consistent with applicable law, we may disclose your
protected health information to organ procurement organizations or other
entities engaged in the procurement, banking, or transplantation of organs,
eyes, or tissue for the purpose of donation and transplant.
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 protected health information.
HEALTH AND SAFETY
To avert a serious threat to health or safety, we
may disclose your protected health information consistent with applicable law
to prevent or lessen a serious, imminent threat to the health or safety of a
person or the public.
SPECIALIZED GOVERNMENTAL FUNCTIONS
We may disclose your protected health information
for specialized government functions as authorized by law such as to Armed
Forces personnel, for national security purposes, or to public assistance
If you are an inmate of a correctional institution,
we may disclose to the institution or its agents the protected health
information necessary for your health and the health and safety of other
If you are seeking compensation through Workers
Compensation, we may disclose your protected health information to the extent
necessary to comply with laws relating to Workers Compensation.
Other Uses and Disclosures
- Other uses and disclosures besides those
identified in this Notice will be made only as otherwise authorized by law
or with your written authorization which you may revoke except to the
extent information or action has already been taken.
- If we maintain a website that provides
information about our entity, this Notice will be on the website. Please go to www.summitmedical.com.
DISCLOSURES REQUIRING YOUR AUTHORIZATION
Psychotherapy notes- authorization must be obtained for any use or
disclosure of psychotherapy notes except to carry out Treatment, Payment, or
Operations or to defend ourselves in a legal action brought by the subject of
Marketing- authorization must be obtained except if the communication
is in the form of a face-to-face communication or in the form of a promotional
gift by your healthcare provider.
Sale- authorization must be obtained prior to any disclosure for the
sale of protected health information.
Date: April 14, 2003
Revised Date: May 1, 2013