Sleep Medicine Associates

Your Health Information Privacy Rights –
This notice describes how medical information about you may be used and how you can obtain access to this information. Please review it carefully

OUR PLEDGE REGARDING YOUR HEALTH INFORMATION:
We understand that your health information is personal and we are committed to protecting that information. We create a record of care and services you receive from us. We need this record to provide you quality care and to comply with certain legal requirements. This notice applies to all health care records generated in our practice.

This notice explains the ways in which we may use and disclose, or share health information about you.

We are required by law to:

• Maintain the privacy of your health information;
• Give you this Notice of our legal duties and privacy practices;
• Follow the terms of this Notice.

What is health information?
Your health information identifies you and relates to:

• Past, present or future physical or mental health condition;
• Treatment we provide to you;
• Payment for past, present or future health care.

Your health information includes your name, address, Social Security number.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Treatment: We will use your health information to determine the best medical care, tests, procedures and medications. We may share your information to coordinate or manage your health care. For example, we may share your information with another health care provider to order a referral, an X-ray or lab work.

Payment: We may use your health information to:

• Check your eligibility for insurance coverage;
• Authorize future treatments and appointments with the Sleep Medicine Center or other health care professionals;
• File for and receive payment for our services.

Health Care Operations: We may share health information about you to perform functions necessary for our business of health care. For example, we may use your information to review services and evaluate the performance of our staff.

Appointment Reminders: We may use your information to contact you with reminders about appointments or prescriptions. Please tell us if you do not wish to be contacted by telephone or want us to use an alternative number.

Research: We may share your health information for research purposes, but only if a review board has determined that your privacy will be appropriately protected. For example, a research project may involve comparing the health and recovery of patient who received one medication to those who received another, for the same condition. We will obtain your permission if the researcher will have access to information that reveals who you are.

Required by Law: We will share your health information when required by law.

Worker’s Compensation: We will share your health information for worker’s compensation or similar programs that provide benefits for work-related injuries or illness.

Public Policy: There are situations when the law requires us to use your health information for public policy purposes.

• Public health concerns: We may share your health information to public health authorities for public activities
  such as reporting births/deaths, preventing/controlling disease, and notifying persons who may have been exposed
  to, or may be at risk for, spreading disease;
• Health oversight activities: We may share your health information to agencies that conduct investigations and inspections necessary for the government to monitor the health care system.

Special Situations: There are situations that require or permit us to share your health information.

• Abuse, neglect, or domestic violence: We may share your information to report suspected abuse, neglect or domestic violence;
• Serious threats to health or safety: We may share your information to avert a threat to the health or safety of you or the public;
• Organ or tissue donation: If an organ donor, we may release information to organizations who handle organ/tissue procurement;
• Problems with products: we may use your health information to report problems with medical devices or products regulated by the Food and Drug Administration or for product recalls, repairs, or replacement;
• Legal proceedings: Nevada Law is more stringent than Federal law, therefore Nevada law is followed. We may share your information in response to a court or administrative order. If information is subpoenaed, we will deliver a
  sealed copy to the court, to be opened only upon direction or order of the court. We will not share your medical information to an attorney in response to a subpoena, except where the attorney provides a signed authorization from you;
• Law enforcement: We may share your health information to comply with the laws that require us to report certain types of injuries, identify or locate a criminal suspect, or provide information about the victim of a crime;
• Coroners, medical examiners and funeral directors: We may share information to a coroner, examiner, or funeral director;
• Specialized government functions: We may share your information as it relates to functions, such as military or veterans activities or national security;
• Inmates: We may share your health information to an institution or custodial official to provide you health care, protect the health and safety of you or others, and maintain the safety and security of the institution.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Right to inspect and copy: You may inspect and copy your health information that might be used to make decisions about your care. Your request must be in writing, and we may charge you a fee for this service. If denied, you may ask that the denial be reconsidered. Your request will be reviewed by a different licensed health care professional.

We will comply with the decision that the professional makes.

Right to amend: You may ask us, in writing, to change information you believe is incorrect or incomplete. You must explain the reason for your request. We may deny your request if the information you are asking us to change:

• Was not created by us (unless the person that created the information is no longer available to make amendments);
• Is not part of the health information kept for or by us;
• Is not part of the information you are permitted to inspect and copy;
• Is already accurate and complete.

If denied, you can file a statement of disagreement with us. Your statement will be included any time we share your information.

Right to an accounting of disclosures: You may request, in writing, a record of disclosures of your health information we may have made. This record will not include all disclosures made for treatment, payment and health care operations. You may ask for up to six years of disclosures. The first record within a 12 month period will be free. We may charge a fee for additional records, but we will notify you of the fee and allow you to withdraw or modify your request. We will mail a list within 30 days of your request, or notify you if we are unable to supply the list.

Right to request restrictions: You may ask us, in writing, to limit how we share your information for treatment, payment and business operations. You may ask that we not share your information with family or friends. We are not required to agree to your request. However, if we do agree, we will comply unless there is an emergency or we are required to use or disclose the information.

Right to request confidential communication: You may ask us, in writing, to communicate with you about health matters in a specific way or location. For example, you may ask that we only contact you at work or by mail. We will comply with reasonable requests.

Right to receive a paper copy of this Notice: You have the right to receive a paper copy of this Notice.

Other uses of health information: Other uses and disclosures of your health information not covered by this notice will be made only with your written permission. You may revoke your permission, in writing, at any time. You have privacy rights under a federal law that protects your health information. If you have questions about them, need to file a complaint or feel your information is not being protected; please contact:

Office of Civil Rights
Hubert H. Humphreys Building
200 Independence Ave. Southwest Rm 509F
Washington, D.C. 20201

Sleep Medicine Associates 
PO Box 692
Cedar City, UT
775-359-6060

YOUR PRIVACY IS VERY IMPORTANT TO US!