THIS PRIVACY NOTICE IS PROVIDED ON BEHALF OF THE FOLLOWING COMPANIES: Fair Lakes Urgent Care Center and its affiliated corporation, STAT Medical Care, P.C., (collectively referred to as “Fair Lakes Urgent Care Center” abbreviated “FLUCC”)

 

FLUCC Commitment to Your Privacy

This Notice of Privacy Practices and Policy (“Notice”) explains the limited degree to which we may collect, use and aggregate personal information about you that you provide to Fair Lakes Urgent Care Center during your visit for care at this facility. This Notice is a component of a new federal law collectively called the “Health Insurance Portability and Accountability Act” (HIPAA). We are required by HIPAA to provide you with this notice. This notice describes our privacy practices, legal duties, and your rights concerning your Protected Information. We are bound by law to follow the privacy practices described in this notice while it is in effect. This notice takes effect April 14th, 2003. It will remain in effect unless and until we publish and issue a new notice.

We understand the confidential nature of the information you provide to Fair Lakes Urgent Care Center. As a medical facility responsible for the information that we collect about you, your privacy is very important to us. We are committed to protecting the confidential nature of your medical information to the full extent of the law. In addition to the various laws governing your privacy, we have gone to great lengths in our office restructuring, systems development and office procedures in place to guarding your Protected Information as required by law. These are designed to protect your information. We fully understand how important it is to protect your privacy and we will continue to make it our priority.

 

Your Acceptance of this Notice

 By agreeing to be evaluated by our physicians and/or the staff member of our facility, you signify your acceptance of the terms of the Fair Lakes Urgent Care Center Notice of Privacy Practices. If you do not agree to the terms of this Notice, it is your right to decline further evaluation from our staff.

We now want you to understand how Fair Lakes Urgent Care Center (FLUCC) may use and disclose certain information you provide us, and what rights you have concerning that information. This privacy policy will tell you:

·          What information is protected

·          How Fair Lakes Urgent Care Center may use and disclose your protected information

·          Your rights concerning your protected information

 

What Information is Protected

Information protected by this privacy policy includes information FLUCC receives or creates that identifies you and concerns:

·          Your past, present or future medical health or condition

·          Medical care that is provided to you, or

·          The past, present or future payment for medical care provided to you.

 

How We May Use or Disclose Protected Information Without Your Authorization

Fair Lakes Urgent Care Center may use or disclose your Protected Health information (PHI) to provide you with treatment, obtain payment for your treatment, or perform health care operations (and are permitted by law) without your permission. Some examples of how we may use or disclose your protected information without your specific authorization include:

·          Treatment: We may use or disclose your PHI to dispense prescription medications or devices to you, provide you with information and counseling, your drug therapy, and communicate with other health care providers including but not limited to your pharmacist, your physician, your physician’s staff, emergency treatment personnel or other health care professionals to ensure you receive appropriate treatment.

·          Payment: We may use or disclose your PHI to determine the amount of your co-payment responsibility and to obtain payment for your treatment from your insurer or employer representative as the case may be.

·          De-Identified Information: Your PHI is altered so that it does not identify you, and even without your name, cannot be used to identify you.

·          Communications with you: We may use your protected information to contact you. We may contact you to check on your medical condition, remind you of need for routine visits to our facility or/and ensure that your prescription is working effectively, or to provide you with information about your laboratory or radiological results.

·          Communications with Family and Friend: If you are unavailable to agree, we may disclose your Protected Information to a family member, friend or other person when the situation dictates that disclosure would be in your best interest. This includes a medical emergency or disaster situation.

·          Health Oversight Agencies: We may disclose your protected information to agencies authorized by law to perform audits, investigations or inspections for the oversight of the health care system, government benefit programs, government regulatory programs or civil rights laws.

·          Law Enforcement, Judicial and Administrative Proceedings:  We may disclose your protected information in response to a court order, administrative order, subpoena, warrant, or other lawful process.

·    Services: We may hire third parties to perform certain services for us. We may disclose your protected information to these third parties so that they can perform the services we have asked them to do. These third parties will be required to protect your information and will not be allowed to use your information for any purpose other than to provide the services we have requested.

·    Public Health Activities: Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease, injury or disability. This includes report of child abuse or neglect.

·    Workers’ Compensation: If you are involved in a Workers’ Compensation claim, the practice may be required to disclose your PHI to an individual entity that is part of the Workers’ Compensation system.

·    Special Circumstances: We may disclose your protected information in certain special circumstances. Such circumstances include disclosures to agencies authorized by law to collect information for national security and intelligence activities, for specialized government functions in the event you are a veteran or are in the military, for investigation of a death or identification of a deceased person, for review of product quality and safety, to avert a threat to health or safety of an individual or the public, or to comply with requirements for worker’s compensation programs. In the event that Fair Lakes Urgent Care Center, or any component of our operations, is merged with, or is acquired by, another entity, then any such successor or acquiring entity may become the successor to our obligations with respect to the personal information that you have provided to FLUCC, which would be necessary for the entity to effectively continue FLUCC’s operations and business.

 

These examples above are for illustration only. They may not be all-inclusive. Fair Lakes Urgent Care Center may also use or disclose your Protected Information as otherwise required by law.  Fair Lakes Urgent Care Center will obtain your written authorization before using or disclosing your protected information for any reasons other than those included in this Privacy Notice. You may revoke your authorization in writing at any time. Upon receipt of your written revocation, we will stop using or disclosing your protected information, except to the extent that we have already taken action in reliance on the authorization.

 

Your Rights

 

You have certain rights concerning your protected information and this Privacy Notice. These rights include:

 

·          Notice. You may request a copy of the Privacy Notice at any time. To request a paper copy, you have to visit our facility.

·          Inspection and Copies. You have the right to inspect and receive a copy of the protected information we maintain about you. To do so, contact our facility and you may be required to submit a written request. We may charge you an administrative to cover our costs of copying and mailing your protected information.

·          Amendments. If you feel that the protected information we maintain about you is incorrect or incomplete, you may request that we amend it. To request an amendment, contact our facility and request to speak with the Office Administrator or our HIPAA Compliance Coordinator. You may be required to submit your amendment request in writing. The request must include the reason you are requesting the amendment. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you may send us a written statement disagreeing with our denial.

·          Restrictions on uses and disclosures. You have the right to request additional restrictions on our use or disclosure of your protected information. You also have the right to request that we restrict disclosures to relatives, friends or other individuals that may be involved in your care or payment for your health care. We are not required to agree to any restrictions you request. Your request must be submitted in writing to Fair Lakes Urgent Care Center.

·          Accounting of disclosures. You have the right to receive an accounting of the disclosures we have made of your protected information.  The  accounting will not include: disclosures made prior to April 14, 2003, disclosures for treatment, payment or health care operations, disclosures made directly to you, your friends or family members involved in your care, disclosures for disaster relief, national security or intelligence purposes, disclosures that are incidental to a permitted use or disclosure or disclosures authorized by you. The right to receive an accounting of disclosures is subject to certain other exceptions, restrictions, and limitations. To request an accounting of disclosures, contact our office administrator or HIPAA Compliance Coordinator. You may be required to submit your request in writing. You may request one such accounting at no charge every 12 months. You may request that the accounting cover up to a 6-year period of reportable disclosures from the date of your request. We will respond within 60 days of your request. We reserve the right to impose a reasonable charge for requests made more than once per year.

·          Alternative Communications. You may request that we contact you about your protected information only in writing or at a different residence. We will accommodate reasonable requests. To make a request, you must submit your request in writing to our office administrator or HIPAA Compliance Coordinator as in the contact information below.

 
Duration of your Consent

       Unless you contact Fair Lakes Urgent Care Center in writing to withdraw your consent for use of your PHI as per the terms of this Notice, your “PHI” will be stored
     and used internally  by Fair Lakes Urgent Care Center indefinitely.


Contacting Us  

Please contact FLUCC Medical Records department using the contact information below if you want:

o         printed copy of our current privacy notice

o         access to your Protected Information,

o         to request an amendment to your Protected Information,

o         to request an accounting of our disclosures of your Protected Information,

o         our center to communicate with you at an alternative address or by alternate means because you believe that you are endangered

o         to request a restriction on our use and disclosure of your Protected Information

 

If you have questions or would like additional information about this practice’s Privacy Notice, you may contact us at Tel (703) 222-3555, or info@flucc.com

If you believe your privacy rights have been violated, you may file a complaint with Fair Lakes Urgent Care Center and with the Secretary of Health and Human Services. To file a complaint with us, send your complaint in writing to HIPAA Compliance Coordinator. There will be no retaliation against you for filing a complaint.

 

Revisions to Notice

Fair Lakes Urgent Care Center may revise the terms of this Notice and may make the new Notice effective for all of your protected information. If we make a material change to this Notice, a new Notice will be posted at the center visible for patients to review, and will be available as well upon request from patients. A copy of any revised notice will also be available on FLUCC’s web site http://www.flucc.com

 

Effective Date

This Privacy Notice is effective as of April 14th, 2003 as required by Health Insurance Portability and Accountability Act (HIPAA) regulations. We are required by Federal law to maintain the privacy of your protected information and to provide you with this Notice.  Fair Lakes Urgent Care Center is required to comply with the terms of this Notice for so long as it is in effect.