PRIVACY POLICY
MARILYN'S MEDICAL FREEDOM
4860 Old Mayfield Road
Paducah, KY 42003
(270) 534-9713 Fax 554-4643
www.marilynsmedical.com
Where Scooters Are Not Just A Sideline.
Acknowledgement of Receipt of the Notice of Privacy Practices
I certify that I have received a copy of the Notice of Privacy
Practices. The Notice of Privacy Practices describes the types
of uses and disclosures of my protected health information that
might occur in my treatment, payment of my bills or in the
performance of Marilyn’s Medical Freedom’s health care
operations. The Notice of Privacy Practices also describes my
rights and Marilyn’s Medical Freedom’s duties with respect to my
protected health information. The Notice of Privacy Practices is
posted in the Showroom.
Marilyn’s Medical Freedom reserves the right to change the
privacy practices that are described in the Notice of Privacy
Practices. I may obtain a revised Notice of Privacy Practices by
calling the office and requesting a revised copy be sent in the
mail or asking for one at the time of my next appointment.
Signature of Patient or Personal Representative
Name of Patient or Personal Representative
Date
Description of Personal Representative’s Authority
Assignment of Benefits
I request that payment of authorized benefits be made on my
behalf to Marilyn’s Medical Freedom for any services furnished
by this provider. However, I understand that I am responsible
for all bills my insurance does not cover.
Signature of Patient or Personal Representative Date NOTICE OF
PRIVACY PRACTICES
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.
This notice takes effect on October 1, 2003 and remains in
effect until we replace it.
1. OUR PLEDGE REGARDING MEDICAL INFORMATION
The privacy of your medical information is important to us. We
understand that you medical information is personal and we are
committed to protecting it. We create a record of the care and
services you receive at our organization. We need this record to
provide you with quality care and to comply with certain legal
requirements. This notice will tell you about the ways we may
use and share medical information about you. We also describe
your rights and certain duties we have regarding the use and
disclosure of medical information.
2. OUR LEGAL DUTY
Law Requires Us to:
Keep your medical information private.
Give you this notice describing our legal duties, privacy
practices, and your rights regarding your medical information.
Follow the terms of the notice that is now in effect.
We Have the Right to:
Change our privacy practices and the terms of this notice at any
time, provided that the changes are permitted by law
Make the changes in our privacy practices and the new terms of
our notice effective for all medical information that we keep,
including information previously created or received before the
changes.
Notice of Change to Privacy Practices:
Before we make an important change in our privacy practices, we
will change this notice and make the new notice available upon
request.
3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways that we use and
disclose medical information. Not every use or disclosure will
be listed. However, we have listed all of the different ways we
are permitted to use and disclose medical information. We will
not use or disclose you medical information for any purpose not
listed below, without you specific written authorization. Any
specific written authorization you provide may be revoked at any
time by writing to us.
FOR TREATMENT: We may use medical information about you to
provide you with medical treatment or services. We may disclose
medical information about you to doctors, nurses, technicians,
medical students, or other people who are taking care of you. We
may also share medical information about you to your other
health care providers to assist them in treating you.
FOR PAYMENT: We may use and disclose your medical information
for payment purposes.
FOR HEALTH CARE OPERATIONS: We may use and disclose your medical
information for our health care operations. This might include
measuring and improving quality, evaluating the performance of
employees, conducting training programs, and getting the
accreditation, certificates, licenses and credentials we need to
serve you.
ADDITIONAL USES AND DISCLOSURES: In addition to using and
disclosing your medical information for treatment, payment, and
health care operations, we may use and disclose, medical
information for the following purposes.
Facility Directory: Unless you notify us that you object, the
following medical information about you will be placed in our
facilities directories: you name; your location in our facility;
your condition described in general terms; your religious
NOTICE OF PRIVACY PRACTICES
affiliation, if any. We may disclose this information to member
of the clergy or, except for you religious affiliation, to
others who contact us and ask for information about you by name.
Notification: Medical information to notify or help notify: a
family member, your personal representative or another person
responsible for your care. We will share information about your
location, general condition.
Disaster Relief: Medical information with a public or private
organization or person who can legally assist in disaster relief
efforts.
Fundraising: We may provide medical information to one of our
affiliated fundraising foundations to contact you for
fundraising purposes. We will limit our use and sharing to
information that describes you in general, not personal, terms
and the dates of health care. In any fundraising materials, we
will provide you a description of how you may choose not to
receive future fundraising communications.
Research in Limited Circumstances: Medical information for
research purposes in limited circumstances where the research
has been approved by a review board that has reviewed the
research proposal and established protocols to ensure the
privacy of medical information.
Funeral Director, Coroner, and Medical Examiner: To help them
carry out their duties we may share the medical information of a
person who has died with a coroner, medical examiner, funeral
director, or an organ procurement organization.
Specialized Government Functions: Subject to certain
requirements, we may disclose or use health information for
military personnel and veterans, for national security and
intelligence activities, for protective services for the
President and others, for medical suitability determinations for
the Department of Sate, for correctional institutions and other
law enforcement custodial situations, and for government
programs providing public benefits.
Court Orders and Judicial and Administrative Proceedings: We may
disclose medical information in response to a court or
administrative order, subpoena, discovery request, or other
lawful process, under certain circumstances. Under limited
circumstances, such as a court order, warrant, or grand jury
subpoena, we may share your medical information with law
enforcement officials. We may share limited information with a
law enforcement official concerning the medical information of a
suspect, fugitive, material witness, crime victim or missing
person. We may share the medical information of an inmate or
other person in lawful custody with a law enforcement official
or correctional institution under certain circumstances.
Public Health Activities: As required by law, we may disclose
your medical information to public health or legal authorities
charged with preventing or controlling disease, injury, or
disability, including child abuse or neglect. We may also
disclose your medical information to persons subject to
jurisdiction of the Food and Drug Administration for purposes of
reporting adverse events associated with product defects or
problems, to enable product recalls, repairs, or replacements,
to track products, or to conduct activities required by the Food
and Drug Administration. We may also, when we are authorized by
law to do so, notify a person who my have been exposed to a
communicable disease or otherwise be at risk of contracting or
spreading a disease or condition.
Victims of Abuse, Neglect, or Domestic Violence: We may disclose
medical information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect, or
domestic violence or the possible victim of other crimes. We may
share your medical information if it is necessary to prevent a
serious threat to your health or safety or the health or safety
of others. We may share medical information when necessary to
help law enforcement officials capture a person who has admitted
to being part of a crime or has escaped legal custody.
Workers Compensation: We may disclose health information when
authorized and necessary to comply with laws relating to workers
compensation or other similar programs.
NOTICE OF PRIVACY PRACTICES
Health Oversight Activities: We may disclose medical information
to an agency providing health oversight for oversight activities
authorized by law, including audits, civil, administrative, or
criminal investigations or proceedings, inspections, licensure
or disciplinary actions, or other authorized activities.
Law Enforcement: Under certain circumstances, we may disclose
health information to law enforcement officials. These
circumstances include reporting required by certain laws (such
as the reporting of certain types of wounds), pursuant to
certain subpoenas or court orders, reporting limited information
concerning identification and location at the request of a law
enforcement official, reports regarding suspected victims of
crimes at the request of a law enforcement official, reporting
death, crimes on our premises, and crimes in emergencies.
4. YOUR INDVIDUAL RIGHTS
You Have a Right to:
Look at or get copies of your medical information. You may
request that we provide copies in a format other than
photocopies. We will use the format you request unless it is not
practical for us to do so. You must make your request in
writing. You may get the form to request access by sending a
letter to the contact person listed at the end of this notice.
If you request copies, we will charge you $ 25.00, and postage
if you want copies mailed to you. Contact us using the
information listed at the end of this notice for a full
explanation of our fee structure.
Receive a list of all the times we or our business associates
shared your medical information for purposes other than
treatment, payment, and healthcare operations and other
specified exceptions.
Request that we place additional restrictions on our use or
disclosure of your medical information. We are not required to
agree to these additional restrictions, but if we do we will
abide by our agreement (except in the case of emergency).
Request that we communicate with you about your medical
information by different means or to different locations. Your
request that we communicate you medical information to you by
different means or at different locations must be made in
writing to the contact person listed at the end of this notice.
Request that we change your medical information. We may deny
your request if we did not create the information you want
changed or for certain other reasons. If we deny your request,
we will provide you a written explanation. You may respond with
a statement of disagreement that will be added to the
information you wanted changed. If we accept your request to
change the information, we will make reasonable efforts to tell
others, including people you name, of the change and to include
the changes in any future sharing of that information.
If you have received this notice electronically, and wish to
receive a paper copy, you have the right to obtain a paper copy
by making a request in writing to:
Jim Fox
Marilyn’s Medical Freedom
4860 Old Mayfield Road
Paducah, KY 42003
Questions and Compliances
If you have any questions about this notice or if you think that
we may have violated your privacy rights, please contact us. You
may also submit a written complaint to the U.S. Department of
Health and Human Services. We will provide you with the address
to file you complaint with the U.S. Department of Health and
Human Services. We will not retaliate in any way if you choose
to file a complaint.
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