Notice of Privacy Practices
To develop and maintain a notice of privacy practices that provides its patients with adequate notice of the uses and disclosures of protected health information that may be made by Infinity Health and of a patient’s rights and Infinity Health’s legal duties with respect to this information. Infinity Health will not use or disclose protected health information in a manner inconsistent with its notice.
How will Infinity Health use and disclose clinical information about you with an appropriate, signed release of information?
For Treatment: We may use clinical information about you to provide you with clinical treatment or services. We may also disclose clinical information about you to doctors, therapists, caseworkers or other authorized personnel involved in your care.
EXAMPLE: A doctor may need to tell your therapist if prescribed medication may require a certain amount of time to take effect. We may share information with outside people if they are also responsible for services related to those you receive here.
For Payment: We may use and disclose clinical information about you so that treatment and services you receive at the center may be billed to and payment may be collected from you, an insurance company, or a third-party payor.
EXAMPLE: We may need to inform your health plan about the treatment you are going to receive to obtain prior approval so your plan will cover treatment. We may need to share information with your insurance company about your treatment plan so your health plan will pay us or to reimburse you.
Other Uses of Your Clinical Information: Other uses and disclosures of clinical information not covered by this notice or the laws that apply to us will be made only with your written permission.
If you provide us with written permission to use or disclose clinical information about you, you may revoke that permission, in writing, at any time.
If you revoke your permission, we will no longer use or disclose clinical information about you for the reasons covered in your written authorization.
We are unable to take back any disclosures we have already made with your permission.
We are required to retain our records of the care we provided to you.
Your Rights Concerning Privacy of Your Clinical Information
You have the right to inspect and receive a copy of your clinical information including clinical and billing records. To inspect and request a copy of your clinical information that may be used to make decisions about you, you must submit a request in writing.
If you request a copy, we may charge a fee to cover the cost of copying, mailing or other costs of other supplies associated with your request.
You have the right to request to amend clinical information you feel is incorrect or incomplete. You may request an amendment for as long as we keep the information.
To request an amendment, your request including a reason to support the request, must be in writing.
We may deny the request for the amendment of clinical information. We may deny your request for amendment if it is not in writing.
We may deny your request for amendment if it does not include a reason to support the request.
We may deny your request for amendment if the information you are requesting to amend was not created by us; unless, the person that created the information is no longer available to make the amendment.
We may deny your request for amendment if it is not part of the information kept by the center.
We may deny your request for amendment if it is not part of the information you would be permitted to inspect.
We may deny your request for amendment if the information is accurate and complete.
You have the right to request a list of the disclosures we made of clinical information about you. Your request must state a time period no longer than six years and not include any dates prior to April 1, 2005.
The first list that you request within a 12-month period will be free of charge. We may charge for the costs of providing additional lists.
We will notify you of the costs involved and you may choose to withdraw, modify or keep your original request at that time before any costs are incurred.
Your request must be made in writing.
For Health Care Operations
We may use and disclose your Protected Health Information (PHI) for internal purposes regarding your care.
EXAMPLE: We may use information within our office to acquire additional recommended treatment possibilities from other clinicians with other experience.
We may combine your information with that of other patients to plan necessary service changes.
We may use information for learning purposes.
We may use information to evaluate the performance of our staff in providing services to you.
We may use this information for appointment reminders.
We may use this information to tell you about treatment alternatives.
We may disclose your PHI externally with appropriate releases as required.
EXAMPLE: We may release information to your insurance company, caregiver or someone who helps pay for your care (legal guardian or guarantor).
We may release information to disaster relief personnel to locate family or you if necessary.
We may combine information from our center with that of other centers for quality review and for evaluating services offered or for research. We may remove information that identifies you from this information.
We will seek specific permission if researchers have access to information that would identify you.
We will disclose information about you when required by federal, state or local law.
Other uses and disclosures we are allowed to make without your explicit authorization. We may release information about you:
For public health activities. These would generally include: report of child or adult abuse or neglect, to notify people of recalls of products, to notify authorities of a victim of abuse, neglect, or domestic violence when authorized by the patient or required by law, and prevention or control of disease.
For your Employee Assistance Program (EAP) or County Central Point of Coordination (CPC) or similar program that provides benefits for you. Limited information may be released.
To a health oversight agency as authorized by law.
If you are involved in a lawsuit, in response to a court or administrative order, or in response to a subpoena, delivery request or other lawful process by another party in the dispute. Efforts will be made to tell you about the request.
To a coroner or medical examiner.
To authorized federal officials in service to protect the President, other heads of state or conduct special investigations.
To the institution or official if you are an inmate of a correctional institution or under custody of law enforcement officials.
To a law enforcement official in response to a court subpoena, warrant summons or other lawful process, to identify a suspect, fugitive, witness or missing person, about a victim, criminal conduct or criminal death. In emergency circumstances concerning crime information.
If you are a member of the armed forces as required by military command authorities.
Your Rights Concerning Privacy of your Protected Health Information
Individuals seeking treatment have the right to request that we restrict our uses and disclosures of their PHI. We are not obliged to agree to those restrictions, but if we do, we must abide by them. Therefore, restrictions to consent will not be granted without the express permission of the Medical Director and/or Executive Director who will evaluate an individual’s request and determine:
- if the restrictions are reasonable and
- if it is possible to implement the restriction in our practice
Should the request be granted, the consent form will reflect the restrictions that have been allowed.
Your request must tell us what information you want to limit, whether you want to limit use or disclosure or both and who you want the limits to apply to. Your request must be made in writing.
You have the right to a paper copy of this notice. You may ask us for a copy of this notice at any time. You may obtain a copy of this notice at the front desk. There will be a copy of this notice posted at our office.
All requests that are required in writing must be sent to:
302 NE 14th Street
Leon, IA 50144
This Privacy Notice may change at the will of the Executive Director and the Board of Directors. Any changes would affect all existing Protected Health Information (PHI). You have a right to a copy of any new revisions if they should become necessary. A copy of the current notice is posted in a public place at the center. You will be offered a copy of the Privacy Notice when you become a client or at a scheduled visit for existing clients.
If you believe your privacy rights have been violated, you may file a complaint with the center or with the Secretary of the Department of Health and Human Services. To file a complaint with the center, the complaint must be submitted in writing to:
302 NE 14th Street
Leon, IA 50144
You will not be penalized for filing a complaint.