Terms & Conditions
Effective Date: 6/7/2023
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW THIS NOTICE CAREFULLY.
1. Summary of Rights and Obligations Concerning Health Information. Kaylee
Pobocik, LLC is committed to preserving the privacy and confidentiality of your
health information, which is required both by federal and state law. We
are required by law to provide you with this notice of our legal duties, your
rights, and our privacy practices, with respect to using and disclosing your
health information that is created or retained by Kaylee Pobocik, LLC. Each
time you visit me, I make a record of your visit. Typically, this record
contains your symptoms, examination and test results, our assessment of your
condition, a record of your treatment interventions, and a plan for future care
or treatment. I have an ethical and legal obligation to protect the privacy of
your health information, and I will only use or disclose this information in
limited circumstances. In general, I may use and disclose your health
information to:
• plan your care and treatment;
• provide treatment by me or others;
• communicate with other providers such as referring physicians;
• receive payment from you, your health plan, or your health insurer;
• make quality assessments and work to improve the care we render and the
outcomes we achieve, known as health care operations;
• make you aware of services and treatments that may be of interest to you; and
• comply with state and federal laws that require us to disclose your health
information.
I may also use or disclose your health information where you have authorized me to do so.
Although your health record belongs to Kaylee Pobocik, LLC, the information in your
record belongs to you. You have the right to:
• ensure the accuracy of your health record;
• request confidential communications between you and your physician and request limits on the use and disclosure of your health information
• request an accounting of certain uses and disclosures of health information I have made about you.
I am required to:
• maintain the privacy of your health information;
• provide you with notice, such as this Notice of Privacy Practices, as to our legal duties and privacy practices with respect to information I collect and maintain about you;
• abide by the terms of my most current Notice of Privacy Practices;
• notify you if I am unable to agree to a requested restriction; and
• accommodate reasonable requests you may have to communicate health information
by alternative means or at alternative locations.
I reserve the right to change my practices and to make the new provisions
effective for all your health information that I maintain.
Should my information practices change, a revised Notice of Privacy Practices will
be available upon request. If there is a material change, a revised Notice of
Privacy Practices will be distributed to the extent required by law. I
will not use or disclose your health information without your authorization,
except as described in our most current Notice of Privacy Practices. In
the following pages, I explain our privacy practices and your rights to your
health information in more detail.
2. I may use or disclose your medical information in the following ways:
Treatment.
I may use and disclose your protected health information to
provide, coordinate and manage your rehab care. That may include
consulting with other health care providers about your health care or referring
you to another health care provider for treatment including physicians, nurses,
and other health care providers involved in your care. For example, I may
release your protected health information to a specialist to whom you have been
referred to ensure that the specialist has the necessary information he or she
needs to diagnose and/or treat you.
·
Payment.
I may use and disclose your health information so that I may
bill and collect payment for the services that I provided to you. For example,
I may contact your health insurer to verify your eligibility for benefits, and
may need to disclose to it some details of your medical condition or expected
course of treatment. I may use or disclose your information so that a bill may
be sent to you, your health insurer, or a family member. The information on or
accompanying the bill may include information that identifies you and your
diagnosis, as well as services rendered, any procedures performed, and supplies
used. If, however, you pay cash at the time of service, I will not disclose
your protected health information to your health plan or any other responsible
payer unless you sign an authorization for me to do so. If I agree to
await payment from your health plan or put you on a payment plan, I may provide
health information to a collection agency, small claims court or other court of
competent jurisdiction in the event your claims for our services are not paid
within 90 days and you have not made alternative payment arrangements with me.
·
Health Care Operations. I may use and disclose your health
information to assist in the operation of my practice. For example, I may
use information in your health record to assess the care and outcomes in your case
and others like it as part of a continuous effort to improve the quality and
effectiveness of the healthcare and services I provide. I may use and disclose
your health information to conduct cost-management and business planning
activities for our practice.
Business Associates. Kaylee Pobocik, LLC sometimes contracts with third-party business associates for services. Examples include answering services, transcriptionists, billing services, consultants, and legal counsel. I may disclose your health information to my business associates so that they can perform the job we have asked them to do. To protect your health information, however, I require our business associates to appropriately safeguard your information.
·
Appointment Reminders. I may use and disclose Information in your medical
record to contact you as a reminder that you have an appointment. I
usually will call or text you the day before your appointment and leave a
message for you on your answering machine or with an individual who responds to
our telephone call. However, you may request that I call you only at a certain
number or that I refrain from leaving messages and I will endeavor to
accommodate all reasonable requests.
·
Treatment Options. I may use and disclose your health information in
order to inform you of alternative treatments.
·
Release to Family/Friends. I, using my professional judgment, may
disclose to a family member, other relative, close personal friend or any other
person you identify, your health information to the extent it is relevant to
that person’s involvement in your care or for payment related to your care. I
will provide you with an opportunity to object to such a disclosure whenever I
practicably can do so. I may disclose the health information of minor children
to their parents or guardians unless such disclosure is otherwise prohibited by
law. However, please note that state law may prohibit us from disclosing
medical information to a parent or guardian at the child’s request if the child
is of a certain age.
·
Health-Related Benefits and Services. I may use and disclose health
information to tell you about health-related benefits or services that may be
of interest to you. In face- to-face communications, such as appointments with
your provider, I may tell you about other products and services that may be of
interest you.
·
Newsletters and Other Communications. I may use your personal information
in order to communicate to you via newsletters (including electronic
newsletters – subject to applicable anti-spam laws), mailings, or other means
regarding treatment options, health related information, disease management
programs, wellness programs, or other community based initiatives or activities
in which my practice is participating.
·
Disaster Relief. I may disclose your health information in disaster
relief situations where disaster relief organizations seek your health
information to coordinate your care, or notify family and friends of your
location and condition. I will provide you with an opportunity to agree or
object to such a disclosure whenever I practicably can do so.
Marketing.
In most circumstances, I am required by law to receive
your written authorization before we use or disclose your health information
for marketing purposes. However, I may provide you with promotional gifts of
nominal value and market services or products to you in face-to-face
communications. Under no circumstances will I sell our patient lists or your
health information to a third party without your written authorization.
Public Health Activities. I may disclose medical information about you
for public health activities. These activities generally include the following:
• licensing and certification carried out by public health authorities;
• prevention or control of disease, injury, or disability;
• reports of births and deaths;
• reports of child abuse or neglect;
• notifications to people who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• organ or tissue donation; and
• notifications to appropriate government authorities if I believe a patient has been the victim of abuse, neglect, or domestic violence. I will make this disclosure when required by law, or if you agree to the disclosure, or when authorized by law and in our professional judgment disclosure is required to prevent serious harm.
Food and Drug Administration (FDA). I may disclose to the FDA and
other regulatory agencies of the federal and state government health information
relating to adverse events with respect to food, supplements, products and
product defects, or post-marketing monitoring information to enable product
recalls, repairs, or replacement.
·
Workers Compensation. I may disclose your health information to the
extent authorized by and to the extent necessary to comply with laws relating
to workers’ compensation or other similar programs established by law.
Law Enforcement. I may release your health information:
• in response to a court order, subpoena, warrant, summons, or similar process of authorized under state or federal law;
• to identify or locate a suspect, fugitive, material witness, or similar person;
• about the victim of a crime if, under certain limited circumstances, I am unable to obtain the person’s agreement;
• about a death I believe may be the result of criminal conduct;
• about criminal conduct at Kaylee Pobocik, LLC;
• to coroners or medical examiners;
• in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime;
• to authorized federal officials for intelligence, counterintelligence, and other national security authorized by law; and
• to authorized federal officials so they may conduct special investigations or provide protection to the President, other authorized persons, or foreign heads of state.
De-identified Information. I may use your health information to create
"de-identified" information or we may disclose your information to a
business associate so that the business associate can create de-identified information
on my behalf. When I "de-identify" health information, I remove
information that identifies you as the source of the information. Health
information is considered "de-identified" only if there is no
reasonable basis to believe that the health information could be used to
identify you.
·
Personal Representative. If you have a personal representative, such as
a legal guardian, I will treat that person as if that person is you with
respect to disclosures of your health information. If you become deceased, I may
disclose health information to an executor or administrator of your estate to
the extent that person is acting as your personal representative.
HLTV-III
Test. If I perform the HLTV-III test on you (to determine if you
have been exposed to HIV), I will not disclose the results of the test to
anyone but you without your written consent unless otherwise required by law. I
also will not disclose the fact that you have taken the test to anyone without
your written consent unless otherwise required by law.
Limited Data Set. I may use and disclose a limited data set that does
not contain specific readily identifiable information about you for research,
public health, and health care operations. I may not disseminate the limited
data set unless we enter into a data use agreement with the recipient in which
the recipient agrees to limit the use of that data set to the purposes for
which it was provided, ensure the security of the data, and not identify the
information or use it to contact any individual.
3. Authorization for Other Uses of Medical Information. Uses
of medical information not covered by our most current Notice of Privacy Practices or
the laws that apply to me will be made only with your written authorization.
You should be aware that I am not responsible for any further disclosures made
by the party you authorize me to release information to. If you provide
me with authorization to use or disclose medical information about you, you may
revoke that authorization, in writing, at any time. If you revoke your
authorization, I will no longer use or disclose medical information about you
for the reasons covered by your written authorization, except to the extent
that I have already taken action in reliance on your authorization or, if the
authorization was obtained as a condition of obtaining insurance coverage and
the insurer has the right to contest a claim or the insurance coverage itself.
I am unable to take back any disclosures I have already made with your
authorization, and I am required to retain our records of the care that I
provided to you.
4. Your Health Information Rights. You have the following rights regarding medical information I gather about you:
A. Right to Obtain a Paper Copy of This Notice. You have the right to a paper copy of this Notice of Privacy
Practices at any time. Even if you have agreed to receive this notice
electronically, you are still entitled to a paper copy.
B. Right to Inspect and Copy. You
have the right to inspect and copy medical information that may be used to make
decisions about your care. This includes medical and billing
records.
To inspect and copy medical information, you must submit a written request to
Kaylee Pobocik, LLC’s privacy officer. I will supply you with a form for such a
request. If you request a copy of your medical information, I may charge a
reasonable fee for the costs of labor, postage, and supplies associated with
your request. I may not charge you a fee if you require your medical
information for a claim for benefits under the Social Security Act (such as
claims for Social Security, Supplemental Security Income, and any other state
or federal needs-based benefit program.
If your medical information is maintained in an electronic health record, you also
have the right to request that an electronic copy of your record be sent to you
or to another individual or entity. I may charge you a reasonable cost based
fee limited to the labor costs associated with transmitting the electronic
health record.
C. Right to Amend. If
you feel that medical information I have about you is incorrect or incomplete,
you may ask me to amend the information. You have the right to request an
amendment for as long as I retain the information.
To request an amendment, your request must be made in writing and submitted to
Kaylee Pobocik, LLC’s privacy officer. In addition, you must provide a reason that
supports your request. I may deny your request for an amendment if it is
not in writing or does not include a reason to support the request. In
addition, I may deny your request if you ask me to amend information that:
• was not created by me, unless the person or entity that created the information is no longer available to make the amendment;
• is not part of the medical information kept by or for Kaylee Pobocik, LLC;
• is not part of the information which you would be permitted to inspect and copy; or
• is accurate and complete.
If I deny your request for amendment, you may submit a statement of
disagreement. I may reasonably limit the length of this statement. Your
letter of disagreement will be included in your medical record, but I may also
include a rebuttal statement.
D. Right to an Accounting of Disclosures.
You have the right to request an accounting of disclosures of your
health information made by me. In your accounting, I am not required to list
certain disclosures, including:
• disclosures made for treatment, payment, and health care operations purposes or
disclosures made incidental to treatment, payment, and health care operations,
however, if the disclosures were made through an electronic health record, you
have the right to request an accounting for such disclosures that were made
during the previous 3 years;
• disclosures made pursuant to your authorization;
• disclosures made to create a limited data set;
• disclosures made directly to you.
To request an accounting of disclosures, you must submit your request in writing
to Kaylee Pobocik, LLC’s privacy officer. Your request must state a time period which
may not be longer than six years and may not include dates before April 14,
2003. Your request should indicate in what form you would like the accounting
of disclosures (for example, on paper or electronically by e-mail). The first
accounting of disclosures you request within any 12-month period will be free.
For additional requests within the same period, I may charge you for the
reasonable costs of providing the accounting of disclosures. I will notify you
of the costs involved and you may choose to withdraw or modify your request at
that time, before any costs are incurred. Under limited circumstances mandated
by federal and state law, I may temporarily deny your request for an accounting
of disclosures.
E. Right to Request Restrictions. You
have the right to request a restriction or limitation on the medical
information I use or disclose about you for treatment, payment, or health care
operations. If you paid out-of-pocket for a specific item or service, you have
the right to request that medical information with respect to that item or
service not be disclosed to a health plan for purposes of payment or health
care operations, and I am required to honor that request. You also have
the right to request a limit on the medical information I communicate about you
to someone who is involved in your care or the payment for your care.
Except as noted above, I am not required to agree to your request. If I do agree, I
will comply with your request unless the restricted information is needed to
provide you with emergency treatment. To request restrictions, you must
make your request in writing to Kaylee Pobocik, LLC’s
privacy officer. In your request, you must tell:
• what information you want to limit;
• whether you want to limit our use, disclosure, or both; and
• to whom you want the limits to apply.
F. Right to Request Confidential
Communications. You have the right to request that I communicate with you about
medical matters in a certain way or at a certain location. For example, you can
ask that I only contact you at work or by e-mail. To request confidential
communications, you must make your request in writing to your provider or the
privacy officer. I will not ask you the reason for your request. I will
accommodate all reasonable requests. Your request must specify how or where you
wish to be contacted.
G. Right to Receive Notice of a Breach. I am
required to notify you by first class mail or by e-mail (if you have indicated
a preference to receive information by e-mail), of any breaches of Unsecured
Protected Health Information as soon as possible, but in any event, no later
than 60 days following the discovery of the breach. “Unsecured Protected Health
Information” is information that is not secured through the use of a technology
or methodology identified by the Secretary of the U.S. Department of Health and
Human Services to render the Protected Health Information unusable, unreadable,
and undecipherable to unauthorized users. The notice is required to include the
following information:
• a brief description of the breach, including the date of the breach and the date
of its discovery, if known;
• a description of the type of Unsecured Protected Health Information involved in
the breach;
• steps you should take to protect yourself from potential harm resulting from
the breach;
• a brief description of actions I am taking to investigate the breach, mitigate
losses, and protect against further breaches;
• contact information, including a toll-free telephone number, e-mail address, Web site or postal address to permit you to ask questions or obtain additional information. In the event the breach involves 10 or more patients whose contact information is out of date I will post a notice of the breach on the home page of our Web site or in a major print or broadcast media. If the breach involves more than 500 patients in the state or jurisdiction, I will send notices to prominent media outlets. If the breach involves more than 500 patients, I am required to immediately notify the Secretary. I also am required to submit an annual report to the Secretary of a breach that involved less than 500 patients during the year and will maintain a written log of breaches involving less than 500 patients.
5. Complaints. If you believe your privacy rights have been violated, you may file a complaint with me or with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. To file a complaint with me, contact the privacy officer at the address listed below. All complaints must be submitted in writing and should be submitted within 180 days of when you knew or should have known that the alleged violation occurred. See the Office for Civil Rights website, www.hhs.gov/ocr/hipaa/ for more information. You will not be penalized for filing a complaint.
If you have any questions about this notice, please contact our privacy officer:
Kaylee Pobocik
hello@kayleepobocik.com
(603) 267-4363