Notice of Privacy Practices

** To Download a printable version of this Privacy Policy Click Here **

Effective date of this Notice: April 14, 2003

As Required by the Privacy Standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. IF YOU HAVE QUESTIONS, PLEASE CONTACT OUR RECEPTIONIST AND SHE WILL HAVE SOMEONE TALK WITH YOU.

OUR COMMITMENT TO YOUR PRIVACY

At Southern Center for Orthopedics, P.C. a/k/a Southern Orthopedics/Sports Medicine and SCO, we are committed to treating and using your protected health information responsibly. As we provide treatment and services to you, we create records that contain your medical and personal information, referred to as "PHI" or Protected Health Information. We need these records to provide you with quality care and to comply with various legal requirements. The terms of this Privacy Notice apply to all records containing your "PHI" that we create and maintain in our office. We are required by federal and state law to maintain the privacy of your "PHI" maintained in such records. We are also required by law to provide you with this Privacy Notice concerning your "PHI". We must follow the terms of the Privacy Notice that we have in effect at the time.

This Privacy Notice provides you with the following important information:

How we may use and disclose your "PHI"
Your privacy rights with respect to your "PHI"
Our obligations concerning the use and disclosure of your "PHI"
Important contact information

UNDERSTANDING YOUR "PHI"/MEDICAL RECORD

Each time you visit Southern Orthopedics/Sports Medicine, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your "PHI" (protected health information) or Medical Record serves as:

A basis for planning your care and treatment
A means of communication among the many health professionals who contribute to your care
A legal document describing the care you received
A means by which you or a third-party payor can verify that services billed were actually provided
A tool in educating health professionals
A source of data for medical research
A source of information for public health officials charged with improving the health of this state and the nation
A source of data for our planning and marketing
A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your PHI/ Medical Record and how your protected health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

HEALTH INFORMATION RIGHTS

Although your health record is the physical property of Southern Orthopedics/Sports Medicine, the information belongs to you.

YOUR RIGHTS INCLUDE

Right to receive a paper copy of our Notice of Privacy Practices upon request
Right to copy and inspect your health record
Right to request an amendment and/or correction to your health record
Right to obtain an accounting of disclosures of your health information
Right to request confidential communications of your health information by alternative means or at alternative locations
Right to request a restriction on certain uses and disclosures of your information
Right to revoke your authorization to use or disclose health information except to the extent that action has already been taken

RESPONSIBILITIES OF SOUTHERN ORTHOPEDICS/SPORTS MEDICINE

Maintain the privacy of your "PHI"/Medical Record
Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
Abide by the terms of this notice
Have the right to change the terms of this agreement
Notify you if this agreement does change
Notify you if we are unable to agree to a requested restriction
Accommodate reasonable requests you may have to communicate health information by alternative means or at an alternative location

We reserve the right to revise or amend this Privacy Notice. Any revision or amendment to this Privacy Notice will be effective for all of your records that our Practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. We will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions and would like additional information, you may contact the practice's Contact Person Gloria W. Kelley, Executive Manager at 706-884-2691.

If you believe your privacy rights have been violated, you can file a complaint with our Privacy Committee or with the Office for Civil Rights, U. S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either our Privacy Committee or the Office for Civil Rights. The address for the Office for Civil Rights is listed below:

Office for Civil Rights
U. S. Department of Health and Human Services
200 Independence Avenue SW
Room 509 F, HHH Building
Washington, DC 20201

WE MAY USE AND DISCLOSE YOUR "PHI" IN THE FOLLOWING WAYS:

The following categories describe and give some examples of the different ways in which we may use and disclose "PHI". Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose your "PHI" will fall within one of the categories listed below.

Treatment. We will use your "PHI" to treat you.

Example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your Medical Record and used to determine the course of treatment that should work best for you. Your physician will document in your medical record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.

We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you are discharged from our care.

Payment. We will use and disclose your "PHI" in order to bill and collect payment from you, an insurance company, or other designated third party payor, for the treatment and services we provide to you.

Example: A bill may be sent to you or a third-party payor (insurance). The information on/or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Healthcare Operations. We will use and disclose your "PHI" to operate our business.

Examples: Members of the medical staff, the risk or quality improvement manager, or members of the Quality Improvement Team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Appointment Reminders. We will use and disclose your "PHI" to contact you and remind you of an appointment.

Example: We will need to use the telephone number you gave us to call and remind you about your appointment or the address you gave us to mail you a reminder.

Treatment Options or Alternatives. We will use and disclose your "PHI" to provide you information about treatment options or alternatives.

Example: If we find out about a new drug that we think would perform better.

Health-Related Benefits and Services. We will use and disclose your "PHI" to inform you of health-related benefits or services that may be of interest to you.

Example: You may be notified of an upcoming Dexa Screening.

Release of Information to Family/Friends. We will release your "PHI" to a friend or family member who is involved in your care, or who assists in taking care of you, to someone who pays, or helps pay for your medical care. You have the right to restrict who receives your medical information. Refer to Section V of this Privacy Notice for the procedure to follow.

Example: To inform your spouse and/or other family member about your diagnosis and/or treatment.

Use and Disclosure of your "PHI" in certain special circumstances. The following categories describe special situations in which we may/will Use or Disclose your "PHI":

Business Associates: There are some services provided in our organization through contacts with business associates.

When services are contracted through a business associate, we may disclose your health information to them so that they can perform the job we've asked them to do and bill you or your third-party payor for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Coroners, Medical Examiners, and Funeral Directors: We will disclose health information to a Medical Examiner or Coroner to identify a deceased individual or to identify the cause of death. We will also release information to Funeral Directors consistent with applicable law to carry out their duties.
Organ procurement organizations: Consistent with applicable law, if you are an organ donor, we will disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Fund Raising: We may contact you, if we have a fund raiser for this office that we think you might benefit from or if we feel that your case would benefit us.
Workers Compensation: We will disclose your "PHI" to the extent authorized by and the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public Health: As required by law, we will disclose your health information to public health or legal authorities for purposes such as, but not limited to, the following:
- Maintaining vital records, such as birth and deaths
- Reporting child abuse or neglect
- Preventing or controlling disease, injury or disability
- Notifying a person regarding potential risk for spreading or contracting a disease or condition
- Reporting reactions to drugs or problems with products or devices
- Notifying individuals if a product or device they may be using has been recalled
- Notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
- Notifying your employer under limited circumstances required by law primarily relating to workplace injury or illness or medical surveillance
Serious Threat to Health or Safety: We will use and disclose your "PHI" when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
Military: We will release your "PHI" as required by the appropriate authorities if you are a member or veteran of US or Foreign Military Forces.
National Security: We will disclose your "PHI" to federal officials for intelligence and national security activities authorized by law. We will also disclose your "PHI" to federal officials in order to protect the President, other official or foreign heads of state, or to conduct investigations.
Correctional Institution: Should you be an inmate of a correctional institution, or under the custody of law enforcement officials, we will disclose your "PHI" to such correctional institutions or law enforcement officials. Disclosure for these purposes would be necessary for the institution to provide healthcare services to you:

For the safety and security of the institution
To protect your health and safety or the health and safety of other individuals

Law Enforcement: We will disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Example:

Reporting certain types of wounds and physical injuries
Regarding a person believed to be a crime victim in certain situations
Concerning a death the healthcare professional suspects has resulted from criminal conduct
Regarding reasonably suspected criminal conduct at our office
In response to a warrant, summons, court order, subpoena or similar legal process
To identify and/or locate a suspect, material witness, fugitive or missing person
In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity, or location of the perpetrator)

As required by Law: We will disclose your "PHI" when we are required to do so by federal, state or local law.

Lawsuits and Similar Proceedings: We may Use and Disclose your "PHI" in response to a Court or Administrative order, if you are involved in a lawsuit or similar proceeding. We may also disclose your "PHI" in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if the requesting party has made an effort to inform you of the request or to obtain a qualified protection order protecting the information the party has requested.

Health Oversight Activities: Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

DIRECT TREATMENT RELATIONSHIP NOTICE

The relationship between you, the patient and Southern Orthopedics/Sports Medicine requires that Southern Orthopedics/Sports Medicine give notice of our privacy practices no later than the first date on which we provide services to you. A copy of our Notice of Privacy Practices is available for review in our waiting room lobby and if you, the patient, wishes to receive a printed copy of our Notice, you can ask for a copy from the receptionist at the front desk and a copy will be given at the initial visit during the interview process.

ELECTRONIC NOTICE

Southern Orthopedics/Sports Medicine maintains a web site. The address is www.southernorthopedics.com. If you, the patient, wish to, you may obtain a copy of our Notice of Privacy Practices by downloading them from our web site. Or if you have e-mail, you may request that we e-mail you a copy.

PAPER NOTICE

If you wish to obtain a copy of our Notice of Privacy Practices to be mailed to you, you may request a copy in writing by mailing your request to Gloria W. Kelley, Contact Person, Privacy Committee, Southern Orthopedics/Sports Medicine, 1805 Vernon Road, Suite B, LaGrange, Georgia 30240.

USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION

RIGHTS REGARDING YOUR "PHI"

You, the patient, have the right to request that Southern Orthopedics/Sports Medicine restrict the Use or Disclosure of your "PHI" for treatment, payment or healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your "PHI" to only certain individuals involved in your care or the payment for your care. We are not required to agree to any such requested restrictions. However, if we do agree, we are bound by our agreement, except when otherwise required or permitted by law, to request a restriction on our use or disclosure of your "PHI", you must make your request in writing to Gloria W. Kelley, Contact Person, Privacy Committee, Southern Orthopedics/Sports Medicine, 1805 Vernon Road, Suite B, LaGrange,, Georgia 30240 and describe in clear and concise fashion;

The information you wish restricted and how you want it restricted Whether you are requesting to limit our Practice's use, disclosure or both To whom you want the limits to apply

However, if we do not agree to the restriction (s), we are entitled to terminate the agreement if you the patient agrees to the termination in writing and/or orally (only if the oral agreement is documented); or if Southern Orthopedics/Sports Medicine informs you that we are terminating our agreement.

CONFIDENTIAL COMMUNICATIONS

You have the right to request that Southern Orthopedics/Sports Medicine communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work, or by mail, rather than telephone. We will accommodate reasonable requests, but are not required to accommodate all requests. In order to request a type of confidential communication, you must make a written request to Gloria W. Kelley, Contact Person, Privacy Committee, Southern Orthopedics/Sports Medicine, 1805 Vernon Road, Suite B, LaGrange, Georgia 30240 specifying the requested method of contact, or the location where you wish to be contacted. You do not need to give a reason for your request.

RIGHT TO AN ACCOUNTING OF DISCLOSURES

You, the patient, have the right to an accounting of all Disclosures of your "PHI" (Protected Health Information) that we have made during the six (6) years, starting April 14, 2003, prior to the date of your request for the accounting.

EXCEPTIONS TO YOUR RIGHT TO AN ACCOUNTING OF DISCLOSURES

Southern Orthopedics/Sports Medicine will not produce an accounting for the following disclosures:

Disclosures to carry out Treatment, Payment and Healthcare Operations
Disclosures of your "PHI" (Protected Health Information) to you
Disclosures to persons involved in your care, for other notification purposes, or for a Facility's directory
Disclosures for national security or intelligence purposes
Disclosures to correctional institutions or Law Enforcement Officials
Disclosures that occurred prior to April 14, 2003

REQUIREMENTS FOR THE DISCLOSURES

Our accounting will include the following:

A list of all Disclosures required to be listed by the accounting, including Disclosures to Business Associates, made during the relevant period of time (as of April 14, 2003)
The date of the Disclosures, the name of the Person receiving the "PHI" (Protected Health Information), and if known, their address, a brief description of the "PHI" (Protected Health Information), and a brief statement of the purpose of the Disclosure or a copy of your Authorization or written request for the Disclosure
For multiple Disclosures to the same Person, the accounting will provide the information required for the first Disclosure, the frequency or number of Disclosures during the relevant period (as of April 14, 2003), and the date of the last Disclosure
The accounting will be made within sixty (60) days from the receipts of the request. However, a one time thirty (30) day extension may be granted if Southern Orthopedics/Sports Medicine provides the patient with a written statement of the reason for the delay and the date of compliance.

The first accounting in any twelve (12) month period will be provided without charge. Thereafter, Southern Orthopedics/Sports Medicine will impose a reasonable cost based fee for any subsequent request received within the same twelve 12 month period. You, the patient, will be notified in advance of the fee, giving you the chance to withdraw or modify your request.

Southern Orthopedics/Sports Medicine will document and retain the information regarding all Disclosures.

RIGHT TO INSPECT AND COPY

You, the patient, have the right to inspect and obtain a copy of your "PHI" including your billing records. You must submit your request in writing to Gloria W. Kelley, Contact Person, Privacy Committee, Southern Orthopedics/Sports Medicine, 1805 Vernon Road, Suite B, LaGrange, Georgia 30240. Our office will charge a fee for the cost of copying, mailing, labor and supplies associated with your request in accordance with Georgia Law.

We may deny your request to copy and/or inspect some of your entire "PHI" in certain limited circumstances; however, you may request a review of our denial. A licensed healthcare professional, who was not involved in the denial, will be chosen by us to conduct a review of the denial. We will comply with the outcome of the review.

You do not have the right to inspect and obtain a copy of your "PHI" (Protected Health Information) contained in the following:

Psychotherapy notes
Information compiled in reasonable anticipation of or for the use in a civil, criminal or administrative action or proceeding
"PHI" (Protected Health Information) that is subject to CLIA
When the Disclosure is prohibited by law or exempt from CLIA

DENIAL OF YOUR RIGHT TO INSPECT AND COPY

Unfettered Denial (Free Understanding)

Southern Orthopedics/Sports Medicine can deny you, the patient, access to your "PHI" (Protected Health Information) without being subject to review in the following circumstances:

An exception applies

If you are an inmate and releasing the information would jeopardize your health, safety, security, custody or rehabilitation, other inmates or any other person at the institution or those responsible for transporting you.

If the "PHI" (Protected Health Information) was created or obtained by Southern Orthopedics/Sports Medicine for research and the research is in progress and you the patient agreed to the denial when you consented to participate in the research and the researcher informed you that your right to access will be reinstated once the research is complete.

"PHI" (Protected Health Information) is contained in records that are subject to the Privacy Rules.

"PHI" (Protected Health Information) was obtained from someone other than a Healthcare Provider pursuant to a promise of confidentiality and access to the information would be reasonably likely to reveal the source of the information.

Review of Denial

In the event of denial in any one of the situations described above, you, the patient, may request a review by a licensed healthcare professional who is designated by Southern Orthopedics/Sports Medicine to review such decisions and who did not participate in the original decision to deny access. The designated reviewer must determine, within thirty days (30) of the written request for the review, whether or not to deny access. The reviewer must provide you with written notice of his/her decision, giving you the reason for the denial, include a statement of your review rights and a description of how you may file a complaint with the Contact Person for the Privacy Committee of Southern Orthopedics/Sports Medicine.

Requirements

Southern Orthopedics/Sports Medicine requires that you, the patient, make your request for access to your "PHI" (Protected Health Information) in writing to Gloria W. Kelley, Contact Person, Privacy Committee, Southern Orthopedics/Sports Medicine, 1805 Vernon Road Suite B, LaGrange, Georgia 30240.

Southern Orthopedics/Sports Medicine will respond to your request within thirty days (30) following the receipt of your request unless the "PHI" (Protected Health Information) that you have requested is maintained off site of the main office. If the information is maintained off site, Southern Orthopedics/Sports Medicine will respond to your request within sixty days (60) following receipt of your request.

Southern Orthopedics/Sports Medicine is entitled to a one time extension of thirty days (30) if we have a problem with the request. If this happens, you, the patient, will be notified of the extension and the reason for the extension.

Southern Orthopedics/Sports Medicine will produce the requested information in a readable hard copy. We will furnish you, the patient, with an actual copy of your "PHI" (Protected Health Information) or with a summary of the information.

Southern Orthopedics/Sports Medicine will charge a fee for accessing/copying your "PHI" (Protected Health Information).

RIGHT TO REQUEST AN AMENDMENT OR CORRECTION TO YOUR "PHI"

You, the patient, have the right to request that Southern Orthopedics/Sports Medicine amend/correct your "PHI" (Protected Health Information).

EXCEPTIONS TO YOUR RIGHT TO REQUEST AN AMENDMENT OR CORRECTION TO YOUR PROTECTED HEALTH INFORMATION

Your request will be denied if Southern Orthopedics/Sports Medicine determines that:

The "PHI" was not created by Southern Orthopedics/Sports Medicine, unless you, the patient, reasonably believe that the originator of your "PHI" (Protected Health Information) is not available to act on the requested amendment/correction.
The "PHI" (Protected Health Information) is not a part of your Designated Medical Record Set
The "PHI" (Protected Health Information) would not be available for inspection
The "PHI" (Protected Health Information) is accurate and complete

REQUIREMENTS

Southern Orthopedics/Sports Medicine requires that your request for amendment/correction to your "PHI" (Protected Health Information) be made in writing and that you state the reason you need the amendment/correction. Send your request to Gloria W. Kelley, Contact Person, Privacy Committee, Southern Orthopedics/Sports Medicine, 1805 Vernon Road Suite B, LaGrange, Georgia 30240.

Southern Orthopedics/Sports Medicine will act on your request within sixty days (60) of receipt of the request if the information requested is maintained on site.

If there is a problem with the request, Southern Orthopedics/Sports Medicine will request a one time extension of thirty days (30). If this occurs, Southern Orthopedics/Sports Medicine will notify you, the patient, of the extension, the reason for the extension and the date by which the request will be completed.

If Southern Orthopedics/Sports Medicine does accept your request for an amendment/correction, an addendum will Be made to your "PHI" (Protected Health Information).

Southern Orthopedics/Sports Medicine will notify you, the patient, that the amendment/correction has been made.

Southern Orthopedics/Sports Medicine will also notify all relevant Persons of the amendment/correction.

You, the patient, can identify and give a list of Persons to Southern Orthopedics/Sports Medicine who will need to be notified of the amendment/correction.

Notification to relevant Persons will be made timely.

DENIAL

If Southern Orthopedics/Sports Medicine denies your request for amendment/correction, we will provide you with a timely written denial that states the following:

The basis for the denial
Your right to submit a written statement disagreeing with the denial
How you, the patient, can file such a statement
That if a statement of disagreement is not submitted, you can request that Southern Orthopedics/Sports Medicine provide your request for amendment/correction and denial with any future Disclosures of your "PHI" (Protected Health Information).
How you, the patient, can complain to the Contact Person of the Privacy Committee of Southern Orthopedics/Sports Medicine, including the name, title, address and telephone number.
In the event that you, the patient, do submit a written statement of disagreement as described above, Southern Orthopedics/Sports Medicine will prepare a written rebuttal and provide you, the patient, with a copy of the rebuttal.
If you, the patient, submit a statement of disagreement disagreeing with Southern Orthopedics/Sports Medicine's denial, Southern Orthopedics/Sports Medicine will include with any request for your "PHI" (Protected Health Information), your request for an amendment/correction, the denial of your request, the statement of disagreement and any rebuttal or a summary of all of this information, with any subsequent Disclosure of your protected health information to which the disagreement relates.
If you, the patient, do not submit a written statement of disagreement, Southern Orthopedics/Sports Medicine will only include the request for the amendment/correction and the denial, or a summary of this information, with any subsequent Disclosure of the protected health information if you, the patient, requested it.
If a Transaction is made that does not permit submission of the additional material, Southern Orthopedics/Sports Medicine will transmit this additional material under separate cover.
If Southern Orthopedics/Sports Medicine denies your request to amend/correct your Protected Health Information, we will identify the protected health information that is the subject of the disputed amendment/correction and append or otherwise link to the Medical Record your request for the amendment/correction, our denial of the request, your statement of disagreement, if any, and our rebuttal, if any.
In all situations, Southern Orthopedics/Sports Medicine will document the title of the Persons or offices responsible for receiving and processing requests for amendments/correction and retain the documentation as described above.

RIGHT TO FILE A COMPLAINT

If you believe your privacy rights have been violated by our Practice or an employee of our Practice, you may file a complaint with our Practice or with the Secretary of the Department of Health and Human Services. Because we are always interested in improving the quality of services provided to you, we would encourage you to contact Gloria W. Kelley, Contact Person, Privacy Committee, Southern Orthopedics/Sports Medicine, 1805 Vernon Road, Suite B, LaGrange, Georgia 30240 with our Practice first. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

RIGHT TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES

We will obtain your written authorization for uses and disclosures that are not identified by this Notice or permitted or required by applicable law. Any authorization you provide to us regarding the use and Disclosure of your "PHI" may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your "PHI" for the reasons described in the authorization.

IF YOU HAVE QUESTIONS ABOUT THIS NOTICE

Please Contact:
GLORIA W. KELLEY, EXECUTIVE MANAGER
CONTACT PERSON PRIVACY COMMITTEE
SOUTHERN ORTHOPEDICS/SPORTS MEDICINE
1805 VERNON ROAD, SUITE B

LAGRANGE, GEORGIA 30240
TELEPHONE 706-884-2691/FAX 706-845-7314