NOTICE OF PRIVACY PRACTICES

THIS NOTICE IS REQUIRED BY LAW (FEDERAL REGULATION 45 CFR PARTS 160 & 164) AND DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
THIS NOTICE IS IN EFFECT ON AND AFTER APRIL 14, 2003

The terms of this Notice of Privacy Practices apply to Western Montana Clinic. We are required by law to maintain the privacy of our patients’ protected health information and to provide patients with notice of our legal duties and privacy practices with respect to your protected health information. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all protected health information maintained by us. You may receive a copy of any revised notices at Western Montana Clinic, Medical Records or a copy may be obtained by mailing a request to: Medical Records, Privacy Officer, at P.O. Box 7609, Missoula, MT 59807.

Uses and Disclosures of Health Information for Treatment, Payment & Healthcare Operations

We use health information about you for treatment (diagnostic testing, medical prescription, referral, etc.), to obtain payment (submit claims and/or encounters to billing services and/or clearinghouses, and/or collection agencies, etc.), for healthcare operations (reporting, utilization management, to evaluate the quality of care that you receive), training of medical students and residents, and participation in medical home by sending PHI to the Montana Health Information Exchange (“Health Share Montana”), etc.

Permitted Uses and Disclosures

Your Authorization: Except as outlined below, we will not use or disclose your protected health information for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization.

Family and Friends Involved in Your Care: With your approval, we may from time to time disclose your protected health information to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited protected health information with such individuals without your approval. We may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.

Required Uses and Disclosures

We are permitted or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization, including but not limited to the following:

• We may release your protected health information for any purpose required by law.

• We may release your protected health information for public health activities, such as required reporting of disease, injury, and birth and death, and for required public health investigations.

• We may release your protected health information as required by law if we suspect child abuse or neglect; we may also release your protected health information as required by law if we believe you to be a victim of abuse, neglect or domestic violence.

• We may release your protected health information to the Food and Drug Administration if necessary to report adverse events, product defects or to participate in product recalls.

• We may release your protected health information to your employer when we have provided health care to you at the request of your employer to determine workplace-related illness or injury, in most cases you will receive notice that information is disclosed to your employer.

• We may release your protected health information if required by law to a government oversight agency conducting audits, investigations or civil or criminal proceedings.

• We may release your protected health information if required to do so by subpoena or discovery request; in some cases you will have notice of such release.

• We may release your protected health information to law enforcement officials as required by law to report wounds and injuries and crimes.

• We may release your protected health information to coroners and/or funeral directors consistent with the law.

• We may release your protected health information if necessary to arrange an organ or tissue donation from you or a transplant for you.

• We may release your protected health information for research purposes, provided that specific procedural steps have been met to ensure the confidentiality of your health information.

• We may release your protected health information if you are a member of the military as required by armed forces services, we may also release your protected health information if necessary for national security or intelligence activities.

• We may release your protected health information to workers’ compensation agencies if necessary for your workers’ compensation benefit determination.

Uses & Disclosures that Require an Authorization

The following uses and disclosures will be made only with your written authorization:

• uses and disclosures for marketing purposes

• uses and disclosures that constitute the sale of Protected Health Information (PHI)

Your Health Information Rights

Although your health record is the physical property of Western Montana Clinic, the information belongs to you. You have the right:

• To copy and/or inspect much of the protected health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative. You may obtain an access request form from Medical Records.

• To request a restriction on certain uses and disclosures of your information. We will honor your request for restrictions to the extent possible. A restriction request form can be obtained from Medical Records. We are not required to agree to your restriction request, unless required by law or you request a restriction to a health plan if you have paid for the services out of pocket and in full, but will attempt to accommodate reasonable requests when appropriate and we retain the right to terminate an agreed-to restriction if we believe such termination is appropriate, in the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction.

• To restrict disclosure of your PHI to the Montana Health Information Exchange “Health Share Montana”.

• To request in writing that protected health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction request. If an amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. You may obtain an amendment request form from Medical Records.

• To request in writing to receive confidential communication from us by alternative means or at an alternative location as provided in 45 CFR 164.522.

• To receive an accounting of certain disclosures made by us of your protected health information six years from the date of the request. Requests must be made in writing and signed by you or your representative. Accounting request forms are available from Medical Records. The first accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you request within the same 12-month period.

• To be notified of a breach of unsecured PHI in the event you are affected.
You will be asked to sign an acknowledgment form that you received this Notice of Privacy Practices.

Questions/Complaints

If you are concerned that we have violated your privacy rights, please contact the privacy officer with any questions or concerns. You may also file a complaint with the U.S. Secretary of Health and Human Services. There will be no retaliation against you for filing a complaint.

Privacy Officer Telephone: (406) 329-7321
Location: Medical Record Department, 500W Broadway, Broadway Building, Level P2
Mailing Address: PO Box 7609, Missoula, Montana 59807

Revised 06/04/2013