*Required fields are marked with an asterisk.
OF PRIVACY PRACTICES
NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION (PHI) MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
REVIEW IT CAREFULLY.
PRIVACY OF YOUR PROTECTED HEALTH INFORMATION (PHI) IS IMPORTANTANCE TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your protected health information (PHI). We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your PHI. We
must follow the privacy practices that are described in this notice while it is in effect.
This notice takes effect September 1, 2013 and will remain in effect until further notice by QFP.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective
for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available
You may request a copy of our Notice of Privacy Practices Statement at any time. For more information regarding our privacy practices, or for additional copies of this notification, please contact us using the information listed at the end of
this notice or you can download our Notice of Privacy Practices Statement from our website at http://www.qualityfamilyphysicians.org
USES AND DISCLOSURES OF PROTECTED HEALTH
Generally, we will obtain your consent before we use and/or disclose your health information. However, we may use and/or disclose your health information without your authorization for the following purposes:
We may use medical information about you to provide medical treatment or services, and we may disclose medical information about you for treatment purposes to doctors, nurses, technicians, or other health care providers who are involved in your
We may use and disclose medical information about you so that the treatment and services you receive from us may be billed and payment may be collected from you and/or an insurance company or third party.
We may use medical information about you to run our practice and support our healthcare operations. For example, we may use your medical information to conduct quality assessment and improvement activities, review the qualifications of health care professionals,
obtain insurance, engage in business planning, provide customer service and resolve grievances, and conduct compliance programs.
We may disclose health information when required by law.
For example, we may release medical information about you without prior authorization for public health purposes, abuse or neglect reporting, and health oversight audits or inspections.
Other Uses of Medical Information
In any situation not covered by this notice or the laws that apply to us, we will ask for your written authorization before using or disclosing medical information about you.
Please note that written authorization is required by you, the patient, before the release of psychotherapy notes, issuance of marketing communications, fundraising (patients must Opt-Out if they do not want fundraising notices), or sale of PHI or ePHI.
QFP at this time has no intention of using your PHI or ePHI for marketing communications or fundraising purposes.
Government Privately Sanctioned Organizations: Quality Family Physicians may inform patients that it participates with state sanctioned organizations to exchange information and patients can obtain further information regarding their
privacy rights relating to the sharing of their information by contacting the Quality Family Physicians office.
In addition to our use of your health information for treatment, payment or healthcare operations, you may give written authorization to use your health information or to disclose it to anyone for any purpose. Your preferred method of external
communications with QFP must be identified on the QFP HIPAA
Patient Data Release & Consent Form and signed by you, our patient.
If you give us authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose
your health information for any reason except those described in this Notice.
To Your Family and Friends:
We must disclose your health information to you, as described in the Patient Rights section of this notice.
We require any person picking up medical information (such as prescriptions, blood work orders, excuse notes, etc.) must know patient’s full name, date of birth and they have a government issued photo ID. If said person does not know your
information, and you have not notified the office, we will refer to the QFP HIPAA Patient Data Release and Consent Form to verify written consent to release the information to that person. Your health information may be disclosed to a
family member, friend, or other person to the extent necessary to help with your healthcare or payment for healthcare.
Persons Involved In Care:
We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general
condition, or death. If you are present, we will provide you with an opportunity to object to such uses or disclosures. In the event of physical or mental inability to manage your affairs or from emergency circumstances, we will disclose health
information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience
with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Quality Family Physicians conducts appointment reminder calls approximately one week before your appointment. (Note: These calls are a patient courtesy; it is the patient’s responsibility to remember their appointments). These appointment reminder
notifications will not include Protected Healthcare Information (PHI) or privacy data.
You have the right to look at or obtain copies of your personal health information (PHI) and medical records by requesting such in writing. Your medical records information may be in the form of a hardcopy or an electronic PDF document format.
QFP will charge you a reasonable fee based on the guidelines defined by the State of Delaware as follows:
$2.00 for first 10 pages
$1.00 per page for pages 11 – 20
$0.90 per page for pages 21-60
$0.50 per page for pages 61 and above
You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an
You have the right to provide us with a written request that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory
explanation how payments will be handled under the alternative means or location you request.
You have the right to receive an accounting of disclosures or a list of persons, outside of the hospital or QFP, who has received information about you. You must request this list in writing and state a time period, not to exceed six years. The
first list you request within a 12-month period shall be provided without cost.
of a Breach:
You have the right to receive notice if there is a breach of your unsecured health information. The notification will be either by e-mail, or a letter mailed to you.
WHO MUST COMPLY WITH THIS NOTICE
All healthcare professionals or employees of Quality Family Physicians with access to your electronic health record (PHI) and our designated Business Associate affiliates/partners must comply with this notice.
QUESTIONS AND CONCERNS
For additional information, questions and/or concerns about our privacy practices, please contact Quality Family Physicians. If you are concerned that we may have violated your privacy rights, you disagree with a decision we made about access to your
health information, or you have concerns about any written requests, you may contact us by using the information listed.
Quality Family Physicians, PA
Dr. Kathleen Willey
Physician/ HIPAA Security & Privacy Officer
722 Yorklyn Road, Suite 400
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
U.S. Department of Health and Human Services
200 Independence Ave. SW
Washington, DC 20201