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Privacy Practices
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Philip Lesorgen, M.D. has instituted
this policy as part of its Compliance Program to reflect its commitment to
comply with applicable federal laws, including but not limited to the Health
Insurance Portability and Accountability Act of 1996 (“HIPAA”), state and
local laws and sound ethical business practices. It is Philip Lesorgen,
M.D.’s policy to provide individuals with a Notice of Privacy Practices
prior to an individual’s first date of service and to make a good faith
effort to obtain written acknowledgment that the Notice was received by the
individual.
Procedures:
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Process. Staff must provide all
individuals with a Notice of Privacy Practices and make a good faith
effort to obtain written acknowledgement that the Notice was received (See
Attachment A). All individuals must receive the Notice after April 14,
2003, the effective date of the Final Privacy Rule.
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Individuals Who Receive the Notice.
All individuals who request treatment from the practice must receive the
Notice as well as those individuals who request a copy of the Notice from
the practice.
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New patients must receive the Notice prior
to their first date of service. The practice may provide the Notice to
the individual in the office prior to his/her visit and is not required
to send the Notice via mail or facsimile prior to the visit.
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Existing patients must receive the Notice
upon their first office visit after the April 14, 2003 compliance
deadline.
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The Privacy Officer will be responsible for
ensuring that an updated version of the Notice is always present on the
practice website.
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Written Acknowledgment. Staff will
take the following steps to obtain written acknowledgement of receipt of
the Notice (See cover page of Attachment A):
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Ask the patient to initial the cover page
of the Notice and return it to the practice (Attachment A); Or
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Ask the patient to initial a separate
acknowledgement list (See Attachment B).
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Staff is not required to obtain written
acknowledgement of the Notice in emergency situations.
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Acknowledgment Not Obtained. Staff is
not required to obtain a signature from an individual. Patient treatment
will not be affected in any manner if an individual fails to provide
written acknowledgement of receipt of the Notice. An individual may
refuse or fail to provide their signature documenting they received the
Notice. If a signature indicating receipt of the Notice cannot be
obtained, staff must:
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Document that a good faith effort to obtain
such acknowledgement was made;
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The efforts taken to obtain the written
acknowledgement of receipt of the Notice; and
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The reason for the failure.
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Documentation must be placed in the
individual’s medical file.
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Review of Notice. The
Privacy Committee will meet on a quarterly basis to discuss practice
adherence to the Notice and to identify any necessary updates or changes
to the Notice.
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Changes to the Notice.
The practice is required to abide by the terms of the Notice, which is
currently in effect. The practice reserves the right to change the terms
of the notice and to make the new Notice provisions effective for all
personal health information the practice already has about an individual
and may obtain in the future.
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The practice must post any
changes to the Notice thirty (30) days prior to making the change
effective.
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All revised notices will be
promptly posted and made available to individuals in the practice
waiting room. The Notice will be posted in the practice waiting room
and will also be available on the practice website
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Changes to the Notice will
only be effective on the date that is reflected at the bottom of the
last page on the revised Notice.
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Business Associates who
handle PHI for or on behalf of the practice must be provided with an
updated Notice within seven business days of the effective date of the
updated Notice.
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Notice Requests.
Individuals may request a current Notice when he/she visits the office. A
current Notice must be kept at the reception desk and provided to
individuals upon request.
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Practice Contact.
If an individual would like more information about the Notice,
Privacy Officer Janet Riso will receive and process all requests at
201-569-6979.
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Compliance. Employees
have a duty to comply with the policies and procedures set forth by the
practice. Any employees found to violate the practices’ policies and
procedures are subject to disciplinary action or corrective measures,
including but not limited to, education and awareness training,
reassignment, additional supervision, disciplinary actions such as
warnings, suspension or termination of employment.
ATTACHMENT A
Philip
Lesorgen, M.D.
106 Grand Ave, Englewood, N.J. 07631
201-569-6979
Notice
of Privacy Practices
I,
_________________________________, acknowledge that I have received the
Notice of Privacy Practices.
Signature
Date
Philip
Lesorgen, M.D.
106 Grand Ave, Englewood, N.J. 07631
201-569-6979
Notice of
Privacy Practices
Summarized
Our practice
is required by law to follow the practices described in this summary. This
is a summary of our Privacy Practices, but does not replace the full
version, which you have also received. This notice describes how medical
information about you may be used and disclosed and how you can get access
to this information. This notice applies to personal health information
that we have about you, and which are kept in or by our medical practice.
Neither this summary nor the full Notice of Privacy Practices covers every
possible use or disclosure. If you have any questions, please contact the
Privacy Officer for this medical practice.
Who has
access to your personal information?
We may
use your personal health information to:
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Plan your
treatment and services.
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Submit bills to your insurance, Medicaid,
Medicare, or third party payer.
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Obtain
approval in advance from your insurance company to determine whether
payment for the treatment is covered by your plan or to facilitate payment
of a referring physician.
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Perform
healthcare operations such as sharing your information with business
associates who need to use or disclose your information to provide a
service for our medical practice (such as our billing company).
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Exchange
information with other State agencies as required by law.
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Treat you in an emergency.
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Treat you when there is something that
prevents us from communicating with you.
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Send you appointment reminders.
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For certain types of research.
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When there is a serious public health or
safety threat to you or others.
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To agencies
involved in a disaster situation.
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As required
by State, Federal, or local law. This includes investigations, audits,
inspections, and licensure.
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To
law enforcement if you are a victim of a crime, involved in a crime at our
facility, or you have threatened to commit a crime.
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To
coroners, medical examiners, and funeral homes when necessary for them to
do their jobs.
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When
ordered to do so by a court.
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To Federal
officials involved in security activities authorized by law.
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To the
correctional facility if you are an inmate.
Patient
Rights.
As a patient in our practice you have the right:
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To ask that
we communicate with you about medical matters in a certain way or at a
certain location. This must be made in writing.
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To inspect
and get a copy of your record (with some exceptions).
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To appeal
if we decide not to let you see all or some parts of your record.
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To ask for
the record to be changed if you believe you see a mistake or something
that is not complete. You must make this request in writing.
We may deny
your request if:
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We did not
create the entry that is wrong; or
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the information is not part
of the file we keep; or
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the information is not part
of the file that we would let you see; or we believe the record is
accurate and complete.
To limit how
we use or disclose information about you. For example – not to release
information to your spouse or a particular provider agency. This must be
made in writing, and we are not required to agree to the request.
To know to
whom we have sent information about you for up to the last six years. The
first request in a 12 month period is free. We may charge you for
additional requests.
To have a
paper copy of the Notice of Privacy Practices.
To file a
complaint if you believe any of your rights have been violated. All
complaints must be in writing. You will not be penalized if you file a
complaint.
To tell us
(authorize) other releases of your personal information not described
above. You may change your mind and remove the authorization at any time
(in writing).
If you wish
to exercise any of these rights, or to file a complaint, you should contact
the Privacy Officer of this medical practice.
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