Dan Martin, MD
UT Medical Group,
Inc.
Germantown Office Building
7945 Wolf River Boulevard
Suite 320
Germantown, Tennessee
TN 38138-1733
(901) 347-8331
(901) 347-8188 fax
Directions to Office
HIPAA Notice
Dan Martin, M.D.
Notice of Privacy Practices for Protected Health Information
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!
If you consent, the office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnosis, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Examples of use of your health information for treatment purposes are:
 | A nurse obtains treatment information about you and records it in a health record. |
| During the course of your treatment, the physician determines he/she will need to consult with another specialist in the area. He/she will share the information with such specialist and obtain his/her input. |
Examples of use of your health information for payment purposes:
| We submit requests for payment to your health insurance company. The health insurance company or business associate helping us to obtain payment requests information from us regarding your medical care given. We will provide information to them about you and the care given. |
Examples of use of your information for Health Care Operations:
| We may obtain services from business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such business associates as necessary to obtain these services. |
| We may, from time to time, participate in investigational programs such as drug studies or performance of investigational procedures. With your permission, your information may be reviewed to determine if you are a candidate to whom this study will be offered. |
Your Health Information Rights
The health and billing records we maintain are the property of the physician's office. You have the following rights with respect to your Protected Health Information:
- Request of restriction on certain uses and disclosures of your health information by delivering the request in writing to our office - we are not required to grant the request but we will comply with any request granted.
- Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our office.
- Right to inspect and copy your health record and billing record - you may exercise this right by delivering the request in writing to our office using the form we provide to you upon request. You may appeal a denial of access to your protected health information.
- Right to request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office I using the form we provide to you upon request. (The physician or other health care provider is not required to make such amendments); you may file a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information.
- Right to receive an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office using the form we provide to you upon request. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care.
- Right to confidential communication by requesting that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office using the form we give to you upon request.
If you want to exercise any of the above rights, please contact Betsy Biggs, Office Manager, at 901-751-0300 in person or in writing, during normal business hours. She will provide you with assistance on the steps to take to exercise your rights.
You have the right to review this Notice before signing the authorization to use and disclose your protected health information for treatment, payment, and health care operations.
Our Responsibilities
The office is required to:
- Maintain the privacy of your health information as required by law;
- Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
- Abide by the terms of the Notice;
- Notify you if we cannot accommodate a requested restriction or request; and
- Accommodate your reasonable requests regarding methods to communicate health information with you.
- Accommodate your request for accounting disclosures.
We reserve the right to amend, change or eliminate provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Betsy Biggs, Office Manager, 901-751-0300.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint with our office by delivering the written complaint to Betsy Biggs. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services whose street address is 200 Independence Avenue SW, Room 6l5F, Washington, DC 20201 and whose e-mail address is hhsmail@os.dhhs.gov.
| We cannot, and will not require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office. |
| We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services |
Following is a list of other uses and disclosures allowed by the Privacy Rule
Patient Contact - We may contact you to provide you with appointment reminders, with information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you. We may contact you as part of a fund-raising effort.
Notification - Opportunity to Agree or Object
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Communication with Family - Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in the payment for such care if you do not object, or in case of emergency.
We may use and disclose your protected health information to assist in disaster relief efforts.
Opportunity to Agree or Object Not Required
Public Health Activities
Controlling Disease - As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Child Abuse & Neglect - We may disclose protected health information to public authorities as allowed by law to report child abuse or neglect.
Food and Drug Administration (FDA) - We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
Victims of Abuse, Neglect, or Domestic Violence - We can disclose protected health information to governmental authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment the doctor believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.
Oversight Agencies - Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities to include audits, civil, administrative or criminal investigations: inspections: licensures or disciplinary actions, and for similar reasons related to the administration of healthcare.
Judicial / Administrative Procedures - We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order or administrative tribunal, provided that only the protected health information released is expressly authorized by such order, or in response to a subpoena, discovery request or lawful process.
Law Enforcement - We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, including laws that require reporting certain types of wounds or other physical injury.
Coroners, Medical Examiners and Funeral Directors - We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
Organ Procurement Organizations - Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.
Research - We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Threat to Health and Safety - To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of other individuals.
For Specialized Governmental Functions - We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
Correctional Institutions - If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety a person or the public.
Workers Compensation - If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
Other Uses and Disclosures - Other uses and disclosures besides those identified in the Notice will be made only as otherwise authorized by law or with your written authorization which you may revoke except to the extent information or actions have already been taken.
Website - If we maintain a website that provides information about our entity, this Notice will be on the website.
Effective Date: April 14, 2003