Notice of Privacy Practices for the Protected Health Information
Effective Date: April 14, 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!

Colorado Comprehensive Spine Institute, LLC (CCSI) 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, test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of Uses of Your Protected Health Information for Treatment Purposes are:

During the course of 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.
Our physician's support staff may obtain treatment information about you and records it in your health record.

Example of Use of Your Health Information for Payment Purposes:

We submit requests for payment to your health insurance company. The health insurance company (or other business associates assisting us to obtain payment) requests information from us regarding medical care given. We will provide information to them about you and the care given.

Example of Use of Your Information for Health Care Operations:

We obtain services from our insurers and other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary.

Your Health Information Rights

The health and billing records we maintain are the physical property of the CCSI. The information in it, however, belongs to you. You have a right to:

Request a restriction on certain uses and disclosures of your health information by delivering the request to our office in writing – we are not required to grant the request, but we may comply with any request granted.

Obtain a paper copy of the current Notice of Privacy Practice for Protected Health Information by making a request at our office, or by visiting our web site at www.coloradospineinstitute.com.

Other Disclosures and Uses

Communication with Family

Using our best judgment, we may or may not 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 payment for such care if you do not object or in an emergency.

Notification

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.

Research

We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved their research.

Disaster Relief

We may use and disclose your protected health information to assist in disaster relief efforts.

Organ Procurement Organizations

Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purposes of tissue donation and transplant.

Food and Drug Administration (FDA)

We may disclose to the FDA your protected health information relating to the adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation

If you are seeking compensation through Workers' Compensation, we may disclose your protected health information to the extent necessary to comply with the laws relating to Workers' Compensation.

Public Health

As authorized by law, we may disclose your protected health information to public health or legal authorities charged with preventing and controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.

Abuse and Neglect

We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Health Oversight

Federal law allows us to release your protected health information to appropriate health oversight activities.

Employers

We may release health information about your to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work – related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosure to your employer will be made only if you execute specific authorization for the release of that information to your employer.

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 of other individuals.

Law Enforcement

We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.

Judicial/Administrative Proceedings

We may disclose your protected health information in the course of any judicial or administrative proceedings as allowed or required by law, with your authorization, or as directed by a proper court order.

Serious Threat

To avert a serious condition threat to health or safety, we may disclose your protected health information consistent with applicable state law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

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.

Coroners, Medical Examiners, and Funeral Directors

We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary for them to carry out their duties.

Other Uses

Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under "Your Health Information Rights".

Web Site

As long as we maintain our web site, this Notice will be available for review at www.coloradospineinstitute.com.

Patients of the Colorado Comprehensive Spine Institute, LLC will receive a printed copy of the above document. Forms in the following format will be presented to the patient for signature, acknowledging his/her receipt of our Privacy Policy.

Acknowledgement of Notice of Privacy Practices

I hereby acknowledge that I received Colorado Comprehensive Spine Institute, LLC's Notice of Privacy Practices.

 

_____________________________ Signature of patient or patient representative

_____________ Date

Documentation of Good Faith Efforts

(For use when acknowledgement cannot be obtained from the patient.)

The patient presented to Colorado Comprehensive Spine Institute, LLC today was provided with a copy of the Notice of Privacy Practices. A good faith effort was made to obtain from the patient a written acknowledgment of his/her receipt of the Notice. However, such acknowledgment was not obtained because:

____ Patient Refused to sign.

____ Patient and/or Patient Representative was unable to sign because:

____ Other reason (described below):

 

_____________________________ Signature of Employee Completing Form

_____________ Date