The Rejuvenation Center

PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND RELEASED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT CAREFULLY.

Effective April 14, 2003

This practice is committed to maintaining the privacy of your protected health information (PHI), which includes information about your health condition and the care and treatment you receive from The Rejuvenation Center. We are required by law to maintain the privacy of protected health information and to provide individuals with a notice of your legal duties and privacy practices. This notice also details your rights regarding your PHI.

The Rejuvenation Center may use and/or release your PHI in the following instances:

PAYMENT: In order to get paid for services provided to you, The Rejuvenation Center will provide you PHI, directly to health insurance companies or other appropriate third party payers pursuant to their billing and payment requirements. For example The Rejuvenation Center may need to provide your health care program with information about health care services that you received from The Rejuvenation Center so that we can be properly reimbursed. We may also need to inform your insurance company about treatment you are going to receive so that it can determine whether or not it will cover the treatment expense.

HEALTH CARE OPERATIONS: In order for the practice to operate in accordance with applicable law and in order for The Rejuvenation Center to continue to provide quality and efficient care, it may be necessary for The Rejuvenation Center to compile, use and/or release your PHI. For example, we may use your PHI in order to evaluate the performance of the practice’s personnel in providing care to you.

Business Associate: Your PHI may be released to a business associate if we obtain satisfactory written guarantee, in accordance with appropriate law, that the business associate will properly guard your PHI. A business associate is an entity that assists us in undertaking some essential function.

Appointment Reminders: We may use your PHI to contact you as a reminder that you have an appointment for medical treatment or care at the clinic.

Personal Representative: Your PHI may be given to a person who, under appropriate law, has the authority to represent you in making decisions related to your health care.

Emergency Situation: We may use your PHI for the purpose of obtaining or giving emergency treatment to you. We may give your PHI to a public or private entity authorized by law to assist in disaster relief efforts, for the purpose of coordinating your care in an emergency situation.

Public Health Activities: Your PHI may be used for public health activities. For example, information collected by a public health authority, as authorized by law, to prevent or control disease.

Abuse, Neglect, or Domestic Violence: Your PHI may be used to notify a government authority if we suspect a patient has been the victim of abuse, neglect, or domestic violence.

Judicial and Administrative Purposes: We may be required to use your PHI in response to a court order or a lawfully issued subpoena.

Worker’s Compensation: If you are involved in a Worker’s compensation claim, we may be required to give your PHI to an individual or entity that is part of the Worker’s Compensation system.

Law Enforcement Purpose: We may release medical information if asked to do so by a law enforcement official.

• In response to court order, subpoena, warrant, summons, or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances we are unable to obtain the person’s agreement;
• About a death we believe may be the result of criminal conduct;
• 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.

Coroner or Medical Examiner: We may give your PHI to a coroner or medical examiner if necessary in determining your cause of death.

Avert a Threat to Health or Safety: We may use your PHI if we believe that such use is necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public and the use is to an individual who is reasonably able to prevent or lessen the threat.

Specialized Government Functions: We may use your PHI for military and veteran activity.

National Security and Intelligence Activities: We may release your PHI in order to provide authorized governmental officials with necessary intelligence information for national security activities and purposes authorized by law.

FAMILY/FRIENDS: We may release to your family member, or other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person’s involvement with your care or the payment for your care. We may also give your PHI to notify or assist in the notification of a family member, a personal representative, or another person responsible for your care, of your location, general condition, or death.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION: You have the right to request restrictions on certain uses and release of your PHI as provided by law. However, we are not obligated to agree to any requested restrictions. You must submit, in writing, a request to our Privacy Officer, the information you want to limit, whether you want the limits to apply to. For example: releasing information to your spouse.

Your have the right to request that we communicate with you in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. You must make your request in writing to our Privacy Officer. We will accommodate all reasonable requests.

You have the right to inspect and copy your PHI as provided by law. You must give us a written request to our Privacy Officer. We can charge you a fee for the cost of copying, mailing, or other supplies. In certain situations as stated by law, we may deny your request but you will have the right to have this reviewed.

You have the right to make changes to your PHI as provided by law. To request an amendment, you must submit a written request to our Privacy Officer. You must give us a reason that supports your request. We may deny your request if it is not in writing, if you do not give us a reason to support your request, if the information to be changed was not created by us (unless the individual or entity that created the information is no longer available.), if the information is not part of your PHI maintained by us, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the denial, you have the right to give us a written statement of disagreement.

You have a right to receive an “accounting of disclosures.” This is a list of companies, agencies, persons who have received your health information except for treatment, payment, or health care operations. To request this, you must submit a written request to our Privacy Officer. Your request must state a time period, which may not be longer than six (6) years, and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free, but we may charge you for the cost of providing additional lists. We will notify you of the cost involved, and you can decide whether you wish to withdraw or change your request before we change you.

You have the right to receive a paper copy of this Privacy Notice from The Rejuvenation Center upon request to our Privacy Officer.

You have the right to file a complaint to The Rejuvenation Center or the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. To file a complaint with The Rejuvenation Center you must contact our Privacy Officer. All complaints must be in writing. We will not retaliate against you for filing a complaint.

You have the right to information about the privacy of your PHI. To obtain more information on, or to have your questions answered, you may contact our Privacy Officer at (402) 391-2635.

We reserve the right to, or may be required by law to change our privacy practices, which may result in changes to this notice. We further reserve the right to make the revised or changed privacy practices notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the office.