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UI Family Care Wapello Privacy Notice

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.

As your health care provider, we are legally required to protect the privacy of your health information, and to provide you with this notice about our legal obligations and privacy practices. This requirement applies to all patients served by UI Family Care- Wapello.

UI Family Care- Wapello is legally required to follow the privacy practices described in this notice. If you have any questions or want more information about this notice, please contact our Privacy Officer listed at the end of this notice.

Your Protected Health Information (PHI)

Throughout this notice, we will refer to your protected health information as PHI. Your PHI includes data that identifies you and reports about the care and services you receive at the hospital, in the clinics, home, or nursing facilities.

This notice applies to all of the records, both electronic and paper, about your care. It includes all information created by UI Family Care- Wapello staff. This staff includes physicians, other health care professionals, health care students and other departmental staff.

This notice about our privacy practices explains how, when, and why we use and share your PHI. We may not use or disclose any more of your PHI than is necessary, with some exceptions. If state law is more protective of your privacy, we will follow state law.

Changes to This Notice

We reserve the right to change the terms of this notice and our privacy policies. Any changes will apply to your past, current, or future PHI. When we make an important change to our policies, we will change this notice and post a new notice on our Web site, www.uihealthcare.com/depts/uicommmedservice. You may also request a copy of our current notice at any time from the University of Iowa Community Medical Services Privacy Officer or UI Family Care -- Wapello clinic Practice Administrator.

Uses of Protected Health Information

UI Family Care - Wapello collects health information about you and store it in a chart and on a computer. This is your medical record. The medical record is the property of UI Family Care -- Wapello, but the information in the medical record belongs to you.

We use and disclose health information for many reasons. The following examples describe some of the categories of our uses and disclosures. Please note that not every use or disclosure in a category is listed.

• Treatment. We may disclose medical information about you to physicians, nurses, technicians, physicians in training, or other health care professionals who are involved with your care. For example, if you are being treated for a knee injury, we may disclose your PHI to the Department of Rehabilitation Therapies if that is where you will receive follow up care. Different health care professionals, such as pharmacists, lab technicians, and x-ray technicians, also may share information about you in order to coordinate your care. In addition, we may send information to the physician who referred you to UI Family Care -- Wapello.

• Payment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. For example, we may provide PHI to an insurance company or other third party payor in order to obtain approval for treatment.

• Health care operations. We may disclose your PHI as part of our routine operations. For example, we may use your PHI to evaluate the quality of health care services you received or to evaluate the performance of health care professionals who cared for you. We may also disclose information to physicians, nurses, technicians, medical students, nursing and other health professional students, and other clinic personnel as part of our educational mission.

• Appointment reminders and health-related benefits or services. We may use your PHI to provide appointment reminders or give you information about treatment alternatives or other health care services.

• Public health activities. We report information about births, deaths, and various diseases to government officials in charge of collecting that information. We provide coroners, medical examiners, and funeral directors with information about an individual's death.

• Law enforcement. We may disclose PHI to government agencies and law enforcement personnel when the law requires it. For example, we report about victims of abuse, neglect, domestic violence, and gunshots, or when ordered to do so in judicial or administrative proceedings.

• Health oversight activities. We may disclose PHI to a health oversight agency for audits, investigations, inspections, and licensure, as authorized by law. For example we may disclose PHI to the Food and Drug Administration, state Medicaid fraud control, or the Department of Health and Human Services Office for Civil Rights

• Research studies. We may use and disclose your PHI to help conduct research. Research may involve finding a cure for an illness or determining the effectiveness of a treatment. All research studies are subject to a specific approval process by a Privacy Board or Institutional Review Board. This process evaluates a proposed research study to determine the measures are in place to balance research needs with the need for the privacy of your health information. For some research activities you may be asked to participate in a study, and if you agree, the researcher will be required to obtain your permission to use your PHI for that study.

• Organ donation. We may use your PHI to notify organ donation organizations, and to assist them in organ, eye or tissue donation and transplants.

• Workers' compensation purposes. We may disclose PHI to your employer or your workers' compensation carrier.

• National security and intelligence activities. We may release PHI to authorized federal officials when required by law. This information may be used to protect the President, other authorized persons or foreign heads of state, to conduct special investigations, for intelligence and other national security activities authorized by law.

Uses and Disclosures for which You Have the Opportunity to Object

• Fundraising. We may use your PHI in efforts to raise money for UI Family Care -- Wapello. We would release contact information only, such as your name, address and phone number, the dates that health care was provided to you, and your insurance status. If you do not want UI Family Care -- Wapello to contact you for fundraising efforts, you must notify our Privacy Officer in writing at the address listed at the end of this notice.

• Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person you tell us is involved in your care or involved in the payment of your health care, unless you object in whole or in part. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest.

Except as described above, all other uses and disclosures of your PHI will require your authorization.

Your Rights Regarding PHI

You have the right to:

• Request Restrictions. You have the right to ask that we limit how we use and disclose your PHI. We will consider your request, but we are not legally required to accept it. If we accept your request, we will honor that request except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make. To request a restriction, contact the Privacy Officer listed at the end of this notice.

• Request Confidential Communications. You have the right to ask that we send PHI to you at an alternate address. For example, you may wish to have appointment reminders and test results sent to a P.O. Box or an address different from your home address. We will accommodate reasonable requests. To make a request, contact UI Family Care -- Wapello.

• Inspect and Copy. You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care. Usually this includes the medical record and billing records. To inspect and obtain a copy of medical information, you must submit your request in writing to UI Family Care - Wapello.

  We will make every effort to respond to your request within a reasonable period of time. You may be charged a fee to cover the costs of copying, mailing, or other supplies associated with your request.

• Accounting of Disclosures. You have a right to obtain a list of instances in which we have disclosed your PHI. Your request must state a time period not longer than six years and may not include dates before April 14, 2003. The list will not include uses or disclosures made for treatment, payment, or health care operations. In addition, the list will not include uses or disclosures that you have specifically authorized in writing such as copies of records to your attorney or to your employer. To request an accounting of disclosures, contact the Privacy Officer listed at the end of this notice.

• Amend. You have the right to request an amendment of your PHI if you think that information is inaccurate or incomplete in your medical record or in a billing record. You may request an amendment for as long as that record is maintained. You may submit a written request for an amendment to the medical record portion to the Privacy Officer listed at the end of this notice. You may submit a written request for an amendment to the billing record portion to UI Family Care -- Wapello.

UI Family Care - Wapello may deny your request for an amendment if:

• it is not in writing
• it relates to information not created or produced by UI Family Care -- Wapello staff
• we decide that the information is accurate and complete

• Paper copy of this notice. You have the right to request a paper copy of this notice. You may pick up a copy at the registration desk of UI Family Care - Wapello or request that one be sent to you. This notice can also be downloaded from www.uihealthcare.com/depts/uicommmedservice.

Revocation of Permission

If you provide us with permission to use or disclose medical information about you, you may revoke that permission at any time. To request revocation of permission, contact the Privacy Officer listed at the end of this notice.

If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written revocation. You understand that we are unable to take back any disclosures previously made with your permission. Also, we are required to keep all records of the care that we provided to you.

Complaints and Questions

If you believe your privacy rights have been violated, you may file a complaint with UI Family Care - Wapello, University of Iowa Community Medical Services, or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with UI Family Care -Wapello, contact the University of Iowa Community Medical Services Privacy Officer at the address and phone number listed at the end of this notice. You will not be penalized for filing a complaint and your care will not be compromised.

UI Family Care- Wapello and University of Iowa Community Medical Services contact information is listed below. Please refer to these contacts for your questions, complaints, or contact's phone numbers and addresses.

If you have any questions about this notice, any complaints about our privacy practices or you would like to have more information, please contact the Privacy Officer listed above.

This notice is in effect April 14, 2003.