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  Notice of Information Practices Pamphlet

Please note that we reserve the right to revise our practices with respect to Protected Health Information and to amend this notice. Any revision or amendment to the Notice will be effective for all of the records our practice has created or maintained in the past and for any records we may create or maintain in the future. We will post a copy of our current Notice and any amended Notice in our offices in a prominent place. We have also posted this Notice below. A paper copy of this Notice is available from any receptionist.

Protected Health Information (PHI)

While receiving care from our facility, information regarding your medical history, treatment, and payment for your health care may be originated and/or received by us. Information which can be used to identify you and which relates to your medical care or your payment for medical care is protected by state and federal law; this is known as “Protected Health Information” (PHI).

Your Rights

Federal law grants you certain rights with respect to your PHI. Specifically, you have the right to:

• Receive a paper copy of this notice;
• Request that certain uses and disclosures of your PHI be restricted or revoked, except to the extent that action has already been taken. However, we are not required to agree to such restrictions unless the disclosure is to a health plan or other payer for purposes of carrying out payment or health care operations and you have personally paid for the services in full;
• Access, review and copy your PHI; This request may be denied in certain limited situations;
• Request that your PHI may be amended; PCI has the discretion to grant or deny the request;
• Obtain an accounting of certain disclosures by us of your PHI. Disclosures from the electronic record will be limited to records going back three years.
• Request receipt of communications in a confidential manner, which may be reasonably accommodated by alternative means or at an alternative location.

How to Exercise Your Rights

All requests must be in writing. We will follow our written policies and notify you of our decision. Contact Health Information to obtain request forms.

Our Responsibilities

Federal law also imposes certain obligations and duties upon us with respect to your PHI. Specifically we are required to:

• Provide you with notice of our legal duties and policies regarding the use and disclosure of your PHI;
• Maintain the confidentiality of your PHI in accordance with state and federal law;
• Notify you of an access, acquisition, use or disclosure of your PHI that is not permitted by HIPAA, if this compromises the security or privacy of your PHI. This is called “breach notification”. We will provide such notice to you without unreasonable delay, but in no case later than 60 days after discovery.
• Abide by the terms of this notice.

How Your PHI May be Used and Disclosed

Federal Law allows us to use or disclose your protected health information without your permission for the following purposes:

• Treatment - Your PHI may be used or disclosed to provide, coordinate or manage your care. For example, we may communicate and share your PHI with other healthcare providers and their staff within and outside PCI to ensure continuity of care. We will seek authorization for PHI concerning mental health treatment, HIV/AIDS, drug or alcohol treatment.
• Payment - Your PHI may be used or disclosed to create bills and collect payment from you, your insurance company or other third party payor. For example, this may include providing information such as dates of service, symptoms, and diagnosis to your insurance company to show we provided medical services to you. 
• Health Care Operations - Your PHI may be used or disclosed for facility operations, which are necessary to ensure that our facility provides the highest quality of care. For example, this may include quality assessment and improvement activities, medical/legal reviews and auditing functions.
• Uses and Disclosures Required by Law - PHI may be used or disclosed for other purposes to the extent required or mandated by law. For example, to comply with ADA, HIPAA privacy or security rule investigation or reviewing by DHS.
• Public Health Activities - Public Health authorities (i.e. FDA & CDC) are legally permitted to collect and/or receive information for their approved activities, including: prevention or control of disease, injury or disability; reporting of reaction to medications or problems with products; notify people of product recalls; notify people who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
• Victims of Abuse, Neglect, or Domestic Violence - In a manner consistent with the requirements of applicable federal and state laws, we may use or disclose PHI to a protective services or social services agency if we reasonably believe you have been the victim of abuse, neglect or domestic violence. This reporting is for the health and safety of the victim.
• Health Oversight Activities - Federal and state agencies may access your PHI to oversee the healthcare activities rendered by our facility or our facility’s compliance with certain laws and regulations.
• Judicial and Administrative Proceedings - We may release PHI in response to a valid court or administrative order, or in response to certain types of subpoena, discovery requests or other lawful process. 
• Law Enforcement - We may release PHI to law enforcement for the following purposes: in response to a court order, warrant, subpoena, summons or similar process; to identify/locate a suspect, fugitive, material witness or missing person; regarding a crime victim if, under certain limited circumstances, we are unable to obtain the person’s agreement; regarding a decedent, if we believe the individual’s death was the result of criminal conduct; regarding criminal conduct at PCI; in emergency circumstances to report a crime, the location of a crime or victims, or the identity, description or location of the person who committed a crime.
• Organ, Eye, or Tissue Donations - PHI may be used or disclosed by us to entities engaged in the procurement, banking or transplantation of organs, eyes or tissues for the purpose of facilitating such donation and transplantation.
• Research Purposes - All research projects are subject to a special approval process that will evaluate the precautions used to protect patient medical information. 
• Serious Threat to Health Safety - PHI may be used or disclosed when necessary to prevent or lessen a serious threat to the health and/or safety of the public, yourself or another person.
• Specialized Government Functions - PHI may be used or disclosed for the following variety of government functions subject to some limitations: military and veterans activities; national security and intelligence activities; protective service of the President and others; medical suitability determinations for Department of State officials; correctional institutions and law enforcement custodial situations; or provision of public benefits.
• Workers’ Compensation - PHI may be used or disclosed as authorized and to the extent necessary to comply with laws relating to workers’ compensation or other programs providing benefits for work-related injuries or illness without regard to fault.
• Patient Contact - At times, unless you object in advance, we may access your PHI to contact you regarding the need to set up an appointment or a reminder about future appointments.

Uses and Disclosure Requiring Your Authorization

Other than the uses and disclosures described herein, we will not use or disclose your protected health information without your written authorization. Specifically, if we do not list a use or disclosure, we will seek your authorization to use or disclose the information. 

Special Uses

Communication with Significant Others
Unless you object, we may exercise professional judgment to determine when disclosures of relevant PHI to a family member, friend or another person is in your best interest. This person would be someone you have identified and indicated as having active interest and/or involvement with your healthcare or payment for your healthcare.

Marketing and Communications Activities
We may use basic demographic information limited to your name, address, phone number and dates you received services to contact you regarding treatment alternatives, health-related benefits, services or community efforts we feel may be of interest to you. If you do not wish to be contacted as part of our marketing and communications efforts, please notify us in writing at:

Physicians’ Clinic of Iowa
Attn: Marketing Department
202 10th Street SE
Cedar Rapids, IA 52403

Comments and Concerns

If you believe your privacy rights have been violated, you may file a complaint with our office by contacting the Quality Improvement Department at 319-247-3010. You may also file a complaint with the Secretary of Health and Human Services. There will be no retaliation for the filing of a complaint.

Effective Date

This notice became effective on April 14, 2003.
Last revised: 9/23/2013

Important Contact Information

This notice has been provided to you as a summary of how we will use PHI and your rights with respect to your PHI. If you have questions or desire more information regarding your PHI, please contact reception at the front desk or the Quality Improvement department at (319) 247-3010.