HOW WILL WE USE AND DISCLOSE YOUR MEDICAL INFORMATION?

Treatment: We may use your medical information to provide you with medical services.  We may also disclose your medical information to others who need that information to treat you, such as doctors, physician assistants, nurse practitioners, nurses, medical and nursing students, technicians, therapists, emergency service and medical transportation providers, medical equipment providers, and others involved in your care. 

We also may use and disclose your medical information to contact you to remind you of an upcoming appointment, to inform you about possible treatment options or alternatives, or to tell you about health-related services available to you.

Family Members and Others Involved in Your Care  We may disclose your medical information to a family member or friend who is involved in your medical care or to someone who helps to pay for your care  If you do not want ASI to disclose your medical information to family members or others, please notify us at the time of your visit.

Payment: We may use and disclose your medical information to obtain payment for the medical services and supplies we provide to you. For example, your health plan or health insurance provider may ask to see parts of your medical record before they remit payment for your treatment. 

Required by Law  Federal, state or local laws sometimes require us to disclose a patient’s medical information. For instance, we are required to report abuse or neglect and must provide certain information to law enforcement officials in domestic violence cases. We are also required to give information to the Arizona Workers’ Compensation Program for work-related injuries.

Public Health: We also may report certain medical information for public health purposes. For instance, we are required to report communicable diseases to the State of Arizona . We also may need to report patient problems with medications or medical products to the FDA or may notify patients of recalls of products they are using.

Health Oversight Activities: We may disclose medical information to a government agency that oversees medical facilities or its personnel, such as the Arizona Department of Health Services, the federal agencies that oversee Medicare, or the Board of Medical Examiners. These agencies need medical information to monitor the facility’s compliance with state and federal laws.

Coroners, Medical Examiners and Funeral Directors:  We may disclose medical information concerning deceased patients to coroners, medical examiners and funeral directors to assist them in carrying out their duties.

Judicial Proceedings: ASI may disclose medical information if we are ordered to do so by a court of law or if the facility receives a subpoena or search warrant. In most situations, you will receive advance notice about this disclosure so you will have opportunity to object to the sharing of your medical information.

Information with Additional Protection: Certain types of medical information have additional protection under state or federal law. For instance, medical information about communicable disease and HIV/AIDS, drug and alcohol abuse/treatment, genetic testing and evaluation/treatment for a serious mental illness is treated differently than other types of medical information. In many instances, ASI is required to get your permission before disclosing that information to others.

Other Uses and Disclosures:  If ASI wishes to use or disclose your medical information for a purpose that is not discussed in this notice, we will seek your permission. If you give permission, you may revoke that permission any time, unless we have already relied on your permission to use or disclose the information.   

WHAT ARE YOUR RIGHTS?

Right to Request Your Medical Information: You have the right to look at and to receive a copy of your own medical information. (The law requires us to keep the original record.) This includes your medical record, your billing record and other records we use to make decisions about your care.  To request your medical information, call our office at the number listed above.  If you request a copy of your information, we may charge you for our costs to copy the information.  We will notify you, in advance, of those copying costs.  You can look at your record at no cost.

Right to Get a List of Certain Disclosures of Your Medical Information: You have the right to request a list of many of the disclosures we make of your medical information. If you would like to receive such a list, submit your request in writing to ASI at the address above. We will provide the first list to you free of charge, but may charge you for any additional lists you request during the same year.  We will notify you, in advance, of the cost for this list.

Right to Request Confidential Communications: You have the right to ask us to communicate with you in a way that you feel is more confidential. For example, you can ask us not to call your home or to communicate only by mail. 

 NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I have received a copy of ASI’s Notice of Privacy Practices.

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Signature of Patient, Patient’s Agent or Representative                                            Date Signed

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Relationship to patient (if not signed by Patient)