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.
USE AND DISCLOSURE OF HEALTH INFORMATION
Daniel B. Jinich MD may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), for purposes of making or obtaining payment for your care and conducting health care operations. Daniel B. Jinich MD has established a policy to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
To Make or Obtain Payment. Daniel B. Jinich MD may use or disclose your health information to make payment to or collect payment from third parties, such as other health plans or providers, for the care you receive. For example, Daniel B. Jinich MD may provide information regarding your coverage or health care treatment to other health plans to coordinate payment of benefits.
To Conduct Health Care Operations. Daniel B. Jinich MD may use or disclose health information for its own operations to facilitate the administration of Daniel B. Jinich MD and as necessary to provide coverage and services to all of his participants. Health care operations includes but not limited to such activities as:
- Quality assessment and improvement activities.
- Activities designed to improve health or reduce health care costs.
- Clinical guideline and protocol development, case management and care coordination.
- Contacting health care providers and participants with information about treatment alternatives and other related functions.
- Health care professional competence or qualifications review and performance evaluation.
- Accreditation, certification, licensing or credentialing activities.
- Underwriting, premium rating or related functions to create, renew or replace health insurance or health benefits.
- Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
- Business planning and development including cost management and planning related analyses and formulary development.
- Business management and general administrative activities of Daniel B. Jinich MD, including customer service and resolution of internal grievances.
- Certain marketing activities.
For example, Daniel B Jinich MD may use your health information to conduct case management, quality improvement and utilization review, and provider credentialing activities or to engage in customer service and grievance resolution activities.
For Treatment Alternatives. Daniel B Jinich MD may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
For Distribution of Health-Related Benefits and Services. Daniel B. Jinich MD may use or disclose your health information to provide to you information on health-related benefits and services that may be of interest to you.
For Disclosure to the Plan Sponsor. Daniel B. Jinich MD may disclose your health information to the plan sponsor for plan administration functions performed by the plan sponsor on behalf of Daniel B. Jinich MD. Daniel B. Jinich MD also may provide summary health information to the plan sponsor so that the plan sponsor may solicit premium bids from other health plans or modify, amend or terminate the plan.
When Legally Required. Daniel B. Jinich MD will disclose your health information when it is required to do so by any federal, state or local law.
To Conduct Health Oversight Activities. Daniel B. Jinich MD may disclose your health information to a health oversight agency for authorized activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Daniel B. Jinich MD, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of or is not directly related to your receipt of health care or public benefits.
In Connection With Judicial and Administrative Proceedings. As permitted or required by state law, Daniel B. Jinich MD may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when Daniel B. Jinich MD makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.
For Law Enforcement Purposes. As permitted or required by state law, Daniel B. Jinich MD may disclose your health information to a law enforcement official for certain law enforcement purposes, including, but not limited to, if Daniel B. Jinich MD has a suspicion that your death was the result of criminal conduct or in an emergency to report a crime.
In the Event of a Serious Threat to Health or Safety. Daniel B. Jinich MD may, consistent with applicable law and ethical standards of conduct, disclose your health information if Daniel B. Jinich MD, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
For Specified Government Functions. In certain circumstances, federal regulations require Daniel B. Jinich MD to use or disclose your health information to facilitate specified government functions related to the military and veterans, national security and intelligence activities, protective services for the president and others, and correctional institutions and inmates.
For Worker's Compensation. Daniel B. Jinich MD may release your health information to the extent necessary to comply with laws related to worker's compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than as stated above, Daniel B. Jinich MD will not disclose your health information other than with your written authorization. If you authorize Daniel B. Jinich MD to use or disclose your health information, you may revoke that authorization in writing at any time.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that Daniel B. Jinich MD maintains:
Right to Request Restrictions. You may request restrictions on certain uses
and disclosures of your health information. You have the right to request a
limit on Daniel B. Jinich MD disclosure of your health information to someone
involved in the payment of your care. However, Daniel B. Jinich MD is not required
to agree to your request. If you wish to make a request for restrictions, please
contact:
Designated HIPAA Privacy Officer
Daniel B. Jinich MD
(970) 221-9991
Right to Receive Confidential Communications. You have the right to request that Daniel B. Jinich MD communicate with you in a certain way if you feel the disclosure of your health information could endanger you. For example, you may ask that Daniel B. Jinich MD only communicate with you at a certain telephone number or by email. If you wish to receive confidential communications, please make your request in writing to:
Designated HIPAA Privacy Officer
Daniel B. Jinich MD
2001 S. Shields E-201
Fort Collins, Colorado 80526
Fax (970) 221-9992
Daniel B. Jinich MD will attempt to honor your reasonable requests for confidential
communications.
Right to Inspect and Copy Your Health Information. You have the right to inspect
and copy your health information. A request to inspect and copy records containing
your health information must be made in writing to:
Designated HIPAA Privacy Officer
Daniel B. Jinich MD
2001 S. Shields E-201
Fort Collins, Colorado 80526
Fax (970) 221-9992
If you request a copy of your health information, Daniel B. Jinich MD. PC may
charge a reasonable fee for copying, assembling costs and postage, if applicable,
associated with your request.
Right to Amend Your Health Information. If you believe that your health information
records are inaccurate or incomplete, you may request that Daniel B. Jinich
MD amend the records. That request may be made as long as Daniel B. Jinich MD
maintains the information. A request for an amendment of records must be made
in writing to:
Designated HIPAA Privacy Officer
Daniel B. Jinich MD
2001 S. Shields E-201
Fort Collins, Colorado 80526
Fax (970) 221-9992
Daniel B. Jinich MD may deny the request if it does not include a reason to
support the amendment. The request also may be denied if your health information
records were not created by Daniel B. Jinich MD, if the health information you
are requesting to amend is not part of Daniel B. Jinich MD records, if the health
information you wish to amend falls within an exception to the health information
you are permitted to inspect and copy, or if Daniel B. Jinich MD determines
the records containing your health information are accurate and complete.
Right to an Accounting. You have the right to request a list of disclosures
of your health information made by Daniel B. Jinich MD for any reason other
than for treatment, payment or health operations as previously defined. The
request must be made in writing to:
Designated HIPAA Privacy Officer
Daniel B. Jinich MD
2001 S. Shields E-201
Fort Collins, Colorado 80526
Fax (970) 221-9992
The request should specify the time period for which you are requesting the
information, but may not start earlier than April 14, 2003. Accounting requests
may not be made for periods of time going back more than two (2) years. Daniel
B. Jinich MD will provide the first accounting you request during any 12-month
period without charge. Subsequent accounting requests may be subject to a reasonable
cost-based fee. Daniel B. Jinich MD will inform you in advance of the fee, if
applicable.
Right to a Paper Copy of this Notice. You have a right to request and receive
a paper copy of this Notice at any time, even if you have received this Notice
previously or agreed to receive the Notice electronically. To obtain a paper
copy, please contact:
Designated HIPAA Privacy Officer
Daniel B. Jinich MD
(970) 221-9991
DUTIES OF DANIEL B. JINICH MD
Daniel B. Jinich MD is required by law to maintain the privacy of your health information as set forth in this Notice and to provide to you this Notice of its duties and privacy practices. Daniel B. Jinich MD is required to abide by the terms of this Notice, which may be amended from time to time. Daniel B. Jinich MD reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If Daniel B. Jinich MD changes its policies and procedures, Daniel B. Jinich MD will revise the Notice and will provide a copy of the revised Notice to you within 60 days of the change. You have the right to express complaints to Daniel B. Jinich MD and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. Any complaints to Health Plan should be made in writing to:
Designated HIPAA Privacy Officer
Daniel B. Jinich MD
2001 S. Shields E-201
Fort Collins, Colorado 80526
Daniel B. Jinich MD encourages you to express any concerns you may have regarding the privacy of your health information. You will not be retaliated against in any way for filing a complaint.
CONTACT PERSON
Daniel B. Jinich MD has designated the Designated HIPAA Privacy Officer as its
contact person for all issues regarding patient privacy and your privacy rights.
You may contact this person at:
Daniel B. Jinich MD
2001 S. Shields E-201
Fort Collins, Colorado 80526
(970) 221-9991
EFFECTIVE DATE
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT:
Designated HIPAA Privacy Officer
Daniel B. Jinich MD
2001 S. Shields E-201
Fort Collins, Colorado 80526
(970) 221-9991