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Privacy Policy

Notice of Privacy Practices

Physicians Laboratory, Ltd.

1000 E 21 st Street, Suite 4100

Sioux Falls, SD 57105

Effective Date of This Notice: April14, 2003

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.

Physicians Laboratory, Ltd. is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about the privacy practices at Physicians Laboratory, Ltd. please contact our Privacy Office at the address or phone number at the bottom of this notice.

Who will follow this notice?

Physicians Laboratory, Ltd. provides health care to our patients in partnership with other physicians and other professionals and organizations. The information privacy practices in this notice will be followed by:

  • All departments and units of our organization in Sioux Falls, Mitchell and Spencer, Iowa
  • All employed associates, staff or volunteer of our company, with whom we may share information.
  • Any business associate (third party that utilizes patient health information on our behalf) or partner with whom we share health information.

Our pledge to you.

We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care that we maintain, whether created by facility staff or your personal physician. Your personal physician may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the physician’s office. We are required by law to:

  • Keep medical information about you private.
  • Give you this notice of our legal duties and privacy practices as it relates to medical information about you.
  • Follow the terms of the notice that is currently in effect.

How Physicians Laboratory, Ltd. may Use or Disclose Your Health Information

Physicians Laboratory, Ltd. collects health information from you and stores it in an electronic chart and on a computer. This is your medical record. The medical record is the property of Physicians Laboratory, Ltd., but the information in the medical record belongs to you. Physicians Laboratory, Ltd. protects the privacy of your health information. The law permits Physicians Laboratory, Ltd. to use or disclose your health information for the following purposes:

  • Treatment . (such as sending medical information about you to a specialist as part of a referral or to coordinate the different things you may need such as prescriptions and lab work.)
  • Payment . (such as sending billing information to your insurance company or Medicare)
  • Regular Health Care Operations . (such as comparing patient data to improve treatment methods or sharing information with medial and nursing students for educational purposes) Disclosures for Treatment, Payment, and Health Care Operations may also be made to members of credentialed medical staff who have an organized health care arrangement with the hospitals Physicians Laboratory, Ltd. serves.

We may use or disclose medical information about you without your prior authorization for several other reasons for example in certain situations such as:

  • Information provided to you .
  • Notification and communication with family . We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
  • Required by law . As required by law, we may use and disclose your health information.
  • Public health . As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.
  • Health oversight activities . We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings.
  • Judicial and administrative proceedings . We may disclose your health information in the course of any administrative or judicial proceeding.
  • Law enforcement . We may disclose your health information to a law enforcement official for purposes such as identifying of locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.
  • Deceased person information . We may disclose your health information to coroners, medical examiners and funeral directors.
  • Organ donation . We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.
  • Research . We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board or <this organization’s> privacy board.
  • Public safety . We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
  • Specialized government functions . We may disclose your health information for military, national security, prisoner and government benefits <only for health plans> purposes. <Note that disclosures for government benefits purposes are limited to health plans only.>
  • Worker’s compensation . We may disclose your health information as necessary to comply with worker’s compensation laws.

When Physicians Laboratory, Ltd. May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, Physicians Laboratory, Ltd. will not use or disclose your health information without your written authorization. If you do authorize Physicians Laboratory, Ltd. to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

Your Health Information Rights

  • In most cases, you have the right to look at or obtain a copy of medical information, when your submit a written request. If you request copes, we may charge a fee for the cost of copying, mailing or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.
  • If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we amend the records, by submitting a request in writing that provides your reason for requesting the amendment. We may deny your request to amend a record if the information was not created by us; if it is not part of the medical information maintained by us; or if we determine that record is accurate. You may appeal, in writing, a decision by us not to amend a record.
  • You have the right to a list of those instances where we have disclosed medical information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure, if you submit a written request. The request must state the time period desire for the accounting, which must be less than a 6-year period and starting after April 14, 2003. The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the fee before you incur any costs.
  • If this notice was sent to you electronically, you have the right to a paper copy of this notice.
  • You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location of us to use to communicate with you.
  • You may request, in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request but we are not legally required to accept it. We will inform you of our decision on your request.

Changes to this Notice of Privacy Practices

We may change our policies at any time and Physicians Laboratory, Ltd. reserves the right to amend this Notice of Privacy Practices at any time in the future, and to make the new provisions effective for all information that it maintains, including information that was created or received prior to the date of such amendment. Until such amendment is made, Physicians Laboratory, Ltd. is required by law to comply with this Notice.

All written requests or appeals should be submitted to our Privacy Office listed at the bottom of this notice.

You can receive a copy of the current notice at any time. The effective date is listed at the beginning of this notice. Upon your initial visit you will also be asked to acknowledge in writing your receipt of this notice.

Complaints

If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Office (listed below). You may also contact Physicians Laboratory, Ltd. at 1-800-658-5474. Finally, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Privacy Office can provide you the address. Under no circumstance will you be penalized or retaliated against for filing a complaint.

You may also address your compliant to one of the regional Offices for Civil Rights. A list of these offices can be found online at http://www.hhs.gov/ocr/regmail.html.

Physicians Laboratory, Ltd.

Attention: Privacy Office

Gary A. Reed, Administrator, Privacy Officer

1000 E 21 st Street Suite 4100


Physicians Laboratory, Ltd.

1000 E 21 st Street, Suite 4100

Sioux Falls, SD 57105

HIPAA Acknowledgement of Receipt of Notice

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. As stated in our notice, the terms of the notice may change. If we change our notice, you may obtain a revised copy by contacting our offices.

By signing this form, you acknowledge that you have received a copy of our Notice of Privacy Practices dated April 14, 2003.

Signed: ____________________________ Date: ____________

Print Name: ________________________ Telephone: ______________

If not signed by the patient, please indicate.

Relationship:

  • Parent or guardian of minor patient
  • Guardian or conservator of an incompetent patient
  • Beneficiary or personal representative of deceased patient

Name of Patient or Patient Representative:_________________________________________

For Office Use Only :

ٱ Signed form received by: ______________________________

ٱ Acknowledgment refused:

Efforts to obtain:

_____________________________________________________________

_____________________________________________________________

Reasons for refusal:

_____________________________________________________________

___________________________________________________________