HIPAA Privacy Notice
This joint 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.
We are required by law to maintain the privacy of your protected health information and to provide you with this notice, which explains our legal duties and privacy practices with respect to your protected health information. We must abide by the terms set forth in this joint notice. However, we reserve the right to change the terms of this joint notice and to make the new notice provisions effective for all protected health information we maintain.
Uses and Disclosures of Your Protected Health Information:
Treatment. We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We may also disclose your protected health information to other health care providers who may be treating you or involved in your health care. For example - we may disclose your protected health information to your treating physician.
Payment. We may use and disclose your protected health information to obtain payment for the health care services we provide you or to determine whether we may obtain payment for services we recommend for you. We may also disclose your protected health information to another health care provider, health care clearinghouse or health plan for services it provided to you. For example - we may include with a bill to a third-party payer information that identifies you, your diagnosis, procedures performed, and supplies used in rendering the service.
Health Care Operations. We may use and disclose your protected health information to support our business activities. For example - we may use your protected health information to review and evaluate our treatment and services or to evaluate our staff's performance while caring for you. We may also disclose your protected health information to third party business associates who perform certain activities for us (e.g., billing or transcription services). Finally, we may disclose to certain third parties a limited data set containing your protected health information for certain business activities.
Appointment Reminders and Treatment Alternatives. We may use and disclose your protected health information to contact you as a reminder about scheduled appointments or treatment, or to tell you about or to recommend possible alternative treatments or other health-related benefits or services that may be of interest to you.
Persons Involved in Your Care. We may use and disclose to a family member, a relative, a close friend, or any other person you identify, your protected health information that is directly relevant to the person's involvement in your care or payment related to your care, unless you object to such disclosure. If you are unable to agree or object to a disclosure, we may disclose the information as necessary if we determine that it is in your best interest based on our professional judgment.
Notification. We may use or disclose your protected health information to notify or assist in notifying a family member, personal representative or other person responsible for your care, of your location, general condition or death.
Disaster Relief. We may use and disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Research. We may use and disclose your protected health information to researchers whose 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. We may also disclose to certain third parties a limited data set containing your protected health information for research purposes.
As Required by Law. We may use and disclose your protected health information to the extent the use or disclosure is required by law. If required by law, you will be notified of any such uses or disclosures.
Public Health. We may disclose your protected health information for public health activities to a public health authority that is permitted by law to collect or receive the information. Disclosures will be made for purposes of controlling disease, injury or disability. If directed by the public health authority, we may disclose your protected health information to a foreign government agency that is collaborating with the public health authority.
Abuse or Neglect. We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. If we believe you are a victim of abuse, neglect or domestic violence, we also may disclose your protected health information to the governmental agency that is authorized to receive this information. All disclosures will be consistent with the requirements of the applicable laws.
Communicable Diseases. If authorized by law, we may disclose your protected health information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a communicable disease.
Legal Proceedings. We may disclose your protected health information in the course of any judicial or administrative proceeding; in response to an order of a court or administrative tribunal; to the extent the disclosure is expressly authorized; or, if certain conditions have been satisfied, in response to a subpoena, discovery request or other lawful process.
Law Enforcement. If certain legal requirements are met, we may disclose your protected health information to a law enforcement official for law enforcement purposes, including legal processes; identification and location of suspects, fugitives, material witnesses or missing persons; information regarding victims of a crime; suspicion that death has occurred as a result of criminal conduct; evidence of criminal conduct occurring on our premises; and, in a medical emergency, reporting criminal conduct not on our premises.
Coroners, Funeral Directors, and Organ Donation: We may disclose your protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose your protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out her duties or in reasonable anticipation of death. Finally, we may use or disclose your protected health information for facilitating organ, eye or tissue donation and transplantation.
To Avert a Serious Threat to Public Health or Safety. Consistent with applicable laws, if we believe using and disclosing your protected health information is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, we may use and disclose your protected health information. We may also disclose your protected health information if it is necessary for law enforcement to identify or apprehend an individual.
Military Activity and National Security. When the appropriate conditions apply, we may use or disclose your protected health information: (1) for activities deemed necessary by appropriate military command authorities; (2) for determining your eligibility for benefits by the Department of Veterans Affairs; or (3) to foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers' Compensation. We may use and disclose your protected health information for workers' compensation or similar programs that provide benefits for work-related injuries or illness.
Department of Health and Human Services. As required by law, we may disclose your protected health information to the Department of Health and Human Services to determine our compliance with applicable laws.
Written Authorization. Except as stated in this joint notice, we will not use or disclose your protected health information without your written authorization. You may revoke this authorization at any time, in writing, except to the extent that we have used or disclosed your information in reliance on the authorization.
Food and Drug Administration. We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements; or to conduct post-marketing surveillance.
Inmates. We may use and disclose your protected health information if you are an inmate of a correctional facility and we created or received your protected health information in the course of providing care to you.
Your Health Information Rights:
Copy of This Joint notice. You have the right to receive a paper copy of this joint notice upon request. You may obtain a copy by asking our receptionist at your next visit or by calling and asking us to mail you a copy. Inspect and Copy. You have the right to inspect and copy the protected health information that we maintain about you in our designated record set for as long as we maintain that information. This designated record set includes your medical and billing records, as well as any other records we use for making decisions about you. You may not inspect or copy psycho-therapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; or protected health information that is subject to law that prohibits access to protected health information. In some circumstances, you may have a right to review our denial. If you wish to inspect or copy your medical information, you must submit your request in writing to the attention of our Privacy Officer, SimonMed Imaging, Inc., 7304 E Deer Valley, Suite 105, Scottsdale, Arizona 85255. Please identify in your request the location or office at which you received services. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request. You may mail your request or bring it to our office. We have 30 days to respond to your request for information that we maintain at our practice sites. If the information is stored off-site, we have up to 60 days to respond, but must inform you of this delay.
Request Amendment. You have the right to request that we amend your protected health information. You must make this request in writing to our Privacy Officer. The request must state the reason for the amendment.
We may deny your request if it is not in writing or does not state the reason for the amendment. We may also deny your request if the information was not created by us, unless you provide reasonable information that the person who created it is no longer available to make the amendment; is not part of the record which you are permitted to inspect and copy; the information is not part of our designated record; or is accurate and complete, in our opinion.
Request Restrictions. You have the right to request a restriction or limitation of how we use or disclose your protected health information for treatment, payment, or health care operations; to persons involved in your care; or for notification purposes as set forth in this joint notice. Although we are not required to agree to your requested restriction, if we do agree, we will comply with your request unless the information is needed for emergency treatment. Please contact our Privacy Officer as set forth in this joint notice to request a restriction.
Accounting of Disclosures. You have the right to request a list of our disclosures of your protected health information, except for disclosures for treatment, payment, or health care operations; to you; incident to a use or disclosure set forth in this joint notice; to persons involved in your care; for notification purposes; for national security or intelligence purposes; to law enforcement officials; as part of a limited data set; that occurred before April 14, 2003 or six years from the date of the request. Your request must be in writing and must state the time period for the requested information.
Your first request for a list of disclosures within a 12 month period will be free. If you request an additional list within 12-months of the first request, we may charge you a fee for the costs of providing the subsequent list. We will notify you of such costs and afford you the opportunity to withdraw your request before any costs are incurred.
Request Confidential Communications. You have the right to request how we communicate with you to preserve your privacy. We may condition the accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. You must submit your request in writing to our Privacy Officer. The request must specify how or where we are to contact you. We will accommodate all reasonable requests.
File a Complaint. You have the right to file a complaint with our Privacy Officer or with the Secretary of the Department of Health and Human Services if you believe we have violated your privacy rights. Complaints to our Privacy Officer/administrator must be in writing. We will not retaliate against you for filing a complaint.
For More Information:
If you have questions or would like additional information, you may contact our Privacy Officer at 602-749-8600
SimonMed Imaging, Inc.
7304 E Deer Valley, Suite 105
Scottsdale, Arizona 85255
Entities Covered by this Joint Notice:
This joint notice applies to SimonMed Imaging, Inc., SMI Imaging, LLC, SimonMed Imaging, a Professional Corporation, all of their office locations, their employees, agents and other members of their workforce. This joint notice does not create an agency relationship, a joint venture or any other legal relationship between the entities covered by this joint notice.