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!

What This Is
This notice describes the privacy practices of Women’s HealthCare Services, PA.

Our Privacy Obligation
We are required by law to maintain the privacy of medical and health information about you and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information (“PHI”.) This notice applies to all records generated or received by Women’s HealthCare Services, PA whether we documented the health information or another doctor forwarded it to us. When we use or disclose PHI, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure.)

Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe in below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:

• Uses and disclosures for Treatment, Payment, and Health Care Operations.
  We may use and disclose PHI (including, if any, your HIV/AIDS related, genetic information, venereal disease or tuberculosis information) in order to treat you, obtain payment for services provided to you and in order to conduct our “health care operations” as detailed below:
  
• Treatment.
  We use and disclose PHI to provide treatment and other services to you, for example, to diagnose and treat your injury or illness. In addition, 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. We may also disclose PHI to other doctors, nurses, technicians, health students, volunteers, or other personnel involved in your treatment. They may work at our office, at a hospital if you are hospitalized under our supervision, or at another doctor’s office, lab, pharmacy, or other healthcare provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes.
  
• Payment.
  We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or a third party. For example, we may need to give your health insurance plan information about your office visit so your health plan will pay us or reimburse you for the visit. In some cases, we may need to tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
  
• Health Care Operations.
  We may use and disclose PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of care that we delivery to you. For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose PHI to our Patient Relations Coordinator in order to resolve any complaints that you may have and ensure that you have a comfortable visit with us. We may remove information that identifies you from this set of health information so others may use it to study healthcare delivery without learning who our specific patients are.

We may also disclose PHI to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or health care fraud and abuse detection or compliance.

• Personal Representatives.
  A personal representative is a legal guardian, a court-appointed individual, or a person designated by you (via a health care power of attorney) to act on your behalf in making decisions related to you health care. We will obtain written documentation of the person’s qualification to act as your personal representative prior to allowing them to make health care decisions on your behalf.
  
• Disclosure to Relatives and Close Friends.
  We may use or disclose PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we 1) obtain your agreement; 2)provide you with the opportunity to object to the disclosure and you do not object; or 3) reasonably infer that you do not object to the disclosure.
  

If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that is directly relevant to the person’s involvement with your health care or payment related to your health care. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.

• Public Health Activities.
  We may disclose PHI for the following public health activities and purposes; 1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; 2) to report child abuse and neglect to public health authorities of other government authorities authorized by law to receive such reports; 3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; and 4) to alert a person who may have been exposed to a communicable disease or may other wise be at risk of contracting or spreading a disease or condition.
  
• Victims of Abuse, Neglect or Domestic Violence.
  If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose PHI to a government authority, including a social service or protective services agency, authorized by law to receive report of such abuse, neglect or domestic violence.
  
• Health Oversight Activities.
  We may disclose PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
  
• Judicial and Administrative Proceedings.
  We may disclose PHI in the course of a judicial or administrative proceeding in response to legal order or other lawful process.
  
• Law Enforcement Officials.
  We may disclose PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
  
• Decedents.
  We may disclose PHI to a medical examiner as authorized by law.
  
• Organ and Tissue Procurement.
  We may disclose PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
  
• Research.
  We may use or disclose PHI without your consent or authorization if an Institutional Review Board approves a waiver of authorization for disclosure.
  
• Health or Safety.
  We may use or disclose PHI to prevent or lessen a threat of imminent, serious physical violence against you or another readily identifiable individual.
  
• Specialized Government Functions.
  We may use and disclose PHI to units of the government with special functions, such as the U.S. military of the U.S. Department of State under certain circumstances.
  
• Worker’s Compensation.
  We may disclose PHI as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.
  
• As Required by Law.
  We may use and disclose PHI when required to do so by any other law not already referred to in the preceding categories.

Uses and Disclosures Requiring Your Written Authorization
Uses or Disclosure with Your Authorization.
For any purpose other than the ones described above in Section III, we only may use or disclose you PHI when: 1) you give us your authorization on our authorization form (“Your Authorization.”) This form is available on our website at www.drtiller.com or in Women’s Health Care Services, PA office.

• Marketing.
  We must also obtain your written authorization (“Your Marketing Authorization”) prior to using your PHI to send you any marketing materials. (We can, however, provide you with marketing materials in a face-to-face encounter, without obtaining Your Marketing Authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining Your Marketing Authorization.) In addition, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings.
  
• Genetic Information.
  Except in cases (such as a paternity test for a court proceeding, anonymous research, newborn screening requirements, or pursuant to a court order), we will obtain your special written consent prior to obtaining or retaining your genetic information (for example, your DNA sample) or using or disclosing your genetic information for any other reason only when Your Authorization expressly refers to your genetic information or when disclosure is permitted under Kansas State law (including, for example, when disclosure is necessary for the purposes of a criminal investigations, to determine paternity, newborn screening, identifying your body or as other wise authorized by court order.)
  
• HIV/AIDS Related Information.
  Your authorization must expressly refer to your HIV/AIDS related information in order to permit us to disclose your HIV/AIDS related information. However, there are certain purposes for which we may disclose your HIV/AIDS information, without obtaining Your Authorization: 1) your diagnosis and treatment; 2) scientific research; 3) management audits, financial audits or program evaluation; 4) medical education; 5) disease prevention and control when permitted by the Kansas Department of Health and Environment; 6) to comply with a certain type of court order; and 7) when required by law, to the Department of Health and Environment or another entity. You also should note that we may disclose your HIV/AIDS related information to third party payors (such as your insurance company or HMO) in order to receive payment for the services we provide to you.
  
• Venereal Disease Information.
  Your authorization must expressly refer to your venereal disease information in order to permit us to disclose any information identifying you as having, or being suspected of having, a venereal disease. However, there are certain purposes for which we may disclose your venereal disease information, without obtaining Your Authorization, including to a prosecuting officer of the court if you are being prosecuted under Kansas law, to the Department of Health and Environment, or to your physician or health authority, such as the local Board of Health. Your physician or a health authority may further disclose your venereal disease information if he/she/it deems it necessary in order to protect the health or welfare of you, your family or the public. Under Kansas laws, we may also grant access to your venereal disease information upon request of a person (or his/her insurance carrier) upon whom you are asserting a claim for compensation or damages for your personal injuries.
  
• Tuberculosis Information.
  Your Authorization must expressly refer to your tuberculosis information in order to permit us to disclose any information identifying you as having tuberculosis or refusing/failing to submit to a tuberculosis test if you are suspected of having tuberculosis or are in close contact to a person with tuberculosis. However, there are certain purposes for which we may disclose your tuberculosis information, without obtaining Your Authorization, including for research purposes under certain conditions, pursuant to a valid court order, or when the Commissioner of the Department of Health and Environment (or his/her designee) determines that such disclosure is necessary to enforce public health laws or to protect the life or health of a named person.

Your Individual Rights
For Further Information:

• Complaints.
  If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to PHI, you may contact our Privacy Official or Compliance Officer. You may also file written complaint with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services, 330 Independence Avenue, SW, Washington, DC 20201.
  
• Right to Request Additional Restrictions.
  You may request restrictions on our use and disclosure of PHI 1) for treatment, payment and health care operations; 2) to individuals (such as family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care; or 3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, you must do so in writing, and direct you request to the Administrative Director of Women’s Health Care Services. We will send a written response.
  
• Right to Receive Confidential Communications.
  You may request, and we will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations. For example, you can ask that we only contact you at work or by mail to a post office box.
  
• Right to Revoke Your Authorization.
  You may revoke Your Authorization or Your Marketing Authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Official identified below. (A form of Written Revocation is available upon request from the Privacy Official.)
  
• Right to Inspect and Copy Your Health Information.
  You may request access to your medical record file and billing records maintained by us in order to inspect and obtain copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Medical Records Department and submit the completed form by mail or in person to the Medical Records Department. If you request copes, per Kansas Law we are able to charge you $0.50 per page for the first 250 pages and $0.35 per page for each additional page over 250, a $15.00 charge for “supplies and labor” may be applied as well as any “reasonable costs” for non-routine duplication (such as x-rays.) If you choose, you may request a summary of the information, which we will prepare at a cost to you of $20.00 per hour. The number of hours required to prepare the summary is dependent upon the size and complexity of your record.
  
  (You should take note that, if you are the parent or legal guardian of a minor, certain portions of the minor’s medical record will not be accessible to you including records related to pregnancy, abortion, sexually transmitted disease, substance abuse, and contraception and/or family planning services.)
  
  
• Right to Amend Your Records.
  You have the right to request that we amend PHI maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Privacy Official and submit the completed for to the Privacy Official. We will comply with you request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
  
• Right to Receive An Accounting of Disclosures.
  Upon request, you may obtain an accounting of certain disclosures of PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge $0.50 per page or $20.00 per hour of the accounting statement.
  
  

Effective Date and Duration of This Notice

• Effective Date.
  This notice is effective on April 14, 2003.
• Right to Change Terms of this Notice.
  We may changes the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in waiting areas around Women’s Health Care Services, PA and on our internet site at www.drtiller.com.
  
  

Compliance Officer and Privacy Official
You may contact the Privacy Official at (316) 684-5108 or:

Privacy Official
Women’s Health Care Services, PA
5107 East Kellogg
Wichita, KS 67218