Samuel U. Rodgers Community Health Center

825 Euclid Ave, Kansas City, MO. 64124

(816) 474-4920

Notice of Privacy Practices

This notice describes how your personal health care information may be used or disclosed and how you can access this information. Please review it carefully.

If you have any questions regarding this notice, please contact our compliance officer at 816-889-4772.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health center operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.   “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may also view this notice on our website at www.samuel-rodgers.org or by calling the health center and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

Understanding Your Health Record/Information

Each time you visit Samuel U. Rodgers Community Health Center, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and plan for future care or treatment. This information, often referred to you as your health or medical record, serves as an:

·         Basis for planning your care and treatment

·         Means of communication among the many health professionals who contribute to your care

·         Legal document describing the care you received

·         Means by which you or a third-party payer can verify that services billed were actually provided

·         A tool to educating health professionals

·         A source of data for medical research

·         A source of information for public health officials charged with improving the health of the nation

·         A source of data for facility planning and marketing

·         A tool with which we can access and continually work to improve the care we render and outcomes we achieve

·         Understanding of what is in your record and how your health information is used to help you to:

1.       Ensure its accuracy

2.       Better understand who, what, when, where and why others may access your health information.

3.       Make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your health record is the physical property of Samuel U. Rodgers Health Center, the information belongs to you. You have the right to:

·         Obtain a paper copy of this Notice of Privacy Practices upon request,

·         Inspect and receive a copy of your health record,

·         Amend your health record ,

·         Obtain an accounting of disclosures of you health information,

·         Request communications of your health information by alternative means or alternative locations,

·         Request a restriction on certain uses and disclosures of your health information, and

·         Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Our Responsibilities

Samuel U. Rodgers Health Center is required to:

·         Maintain the privacy of your health information,

·         Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you,

·         Abide by the terms of this notice,

·         Notify you if we are unable to agree to a requested restriction, and

·         Accommodate reasonable requests you may have to communicate health information by alternative means or alternative locations.

We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.

To Report A Problem

If you believe your privacy rights have been violated, you can file a complaint with our Corporate Compliance Officer (816-889-4772) or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Compliance Officer or the Office for Civil Rights (OCR). The address for the OCR is listed below:

Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Ave, S.W.

Room 509 F, HHH Building

Washington, D.C. 20201

Compliance Officer

Samuel U. Rodgers Health Center

825 Euclid Ave

Kansas City, MO 64124

Uses and Disclosures of Protected Health Information

Your patient information will be used for treatment, payment and health care operations. It may be used and disclosed by your provider, our office staff and others outside of our clinic that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the Health Center’s practice.

The following are examples of the types of uses and disclosures of your health care information that this clinic is permitted to make once you have consented to treatment. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

Treatment: Information obtained by a nurse, physician, or other team member of our health care team will be recorded in your record and used to determine the course of treatment that should work best for you. We will use and disclose this information to provide, coordinate, or manage your health care and any related services. This includes providing information to a third party such as another physician for a referral, a specialist, or a laboratory.

Payment: Your protected health information will be used, as needed to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

HealthCare Operations:   We may use or disclose, as needed, your health information in order to support the business activities of the health center. These activities include, but are not limited to, quality assessment activities, employee review activities, and training of medical students, research, marketing and fundraising activities, and conducting other business.

For example, we may disclose your protected information to medical students that see patients at our clinic. In addition, we may use a sign-in sheet in the clinic where you will be asked to sign your name and indicate your provider. We may also call you by name in the waiting room when your provider is ready to see you. We may use or disclose your protected information, as necessary, to contact you to remind you of your appointment.

We will share your protected information with third party “business associates” that perform various activities (e.g. billing, transcription services) for the health center. Whenever an arrangement between our office and a business associate involves the use or disclosure of health information, we will have a written contract that contains terms that will protect the privacy of your health information.

We may use or disclose information, as necessary, to provide you with information about treatment alternatives or other health related benefits and services that may be of interest to you. We may also use your information for other marketing activities. For example, your name and address may be used to send you a newsletter about our clinic and the services we offer. You may contact our Compliance Officer to request that these materials not be sent to you.

Uses and Disclosures of Protected Health Information based upon your written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your provider or this organization has taken an action in reliance on the use or disclosure indicated in the authorization.

Other permitted and Required Uses and Disclosures that may be made Without Your Consent or Authorization

Emergencies: We may use or disclose your health information in an emergency treatment situation. If this happens, your provider shall try to obtain your consent as soon as reasonably practicable after delivery of treatment. If your provider or another provider at this facility is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected information to treat you. This also applies if an outside health care organization requests your health information in an emergency situation and you are unable to give authorization and the purpose of disclosure is for treatment.

Communication Barriers: We may use and disclose your patient information if your provider attempts to treat or obtain consent from you but is unable to do so due to communication barriers. The provider must determine, using professional judgement that you intend to consent to use or disclose information under the circumstances. In addition, an interpreter may be used to translate information for treatment, payment or other health center operations.

Required by Law: Your health information may be used or released as required by law. The information given will be limited to relevant requirements of the law. You will be notified, as required by law, of such uses.

Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Food and Drug Administration: We may release your health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, and track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: Your health information may be used or disclosed in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: Your information can be used for the following law enforcement purposes; (1) legal processes, (2) limited information requests for identification and location purposes, (3) pertaining to victims of crime, (4) suspicion that death has occurred, (5) in the event that a crime occurs on these premises, and (6) medical emergency and its is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes or determining the cause of death. We may also disclose information to a funeral director, as authorized by law, in order to permit the funeral home to carry out their duties. Information may be released to organ procurement organizations or other agencies engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and organ 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 health information.

Workers Compensation: Protected health information may be disclosed to the extent authorized by and necessary to comply with laws relating to workers compensation or other similar programs.

Correctional Institutions: If you are an inmate of a correctional institution, we may disclose to the institution or agents there of health information necessary for your health and the health and safety of others individuals.

Notification: Your health information may be disclosed to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location and general condition.

Communication with family: Health professionals, using their best judgement, 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 payment related to your care.

Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority, or an attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

Effective Date: 04-07-03

Revised Date:    08/31/2011