Notice of Privacy Practice
NOTICE OF PRIVACY PRACTICE
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.
Personally identifiable information about your health, your health care, and your payment for health care is called Protected Health Information. We must safeguard your Protected Health Information and give you this Notice about our privacy practices that explains how, when and why we may use or disclose your Protected Health Information. Except in the situations set out in the Notice, we must use or disclose only the minimum necessary Protected Health Information to carry out the use or disclosure.
You may obtain a copy of the Notice by calling us at (317) 804-3501 and asking us to mail you a copy or by asking for a copy at your next appointment.
Uses and Disclosures of Your Protected Health Information That Do Not Require Your Consent
Mental health information, including psychological or psychiatric treatment records and psychotherapy notes, and information relating to communicable diseases, including HIV records, are subject to special protections under Indiana law. We will generally only release such records or information with your written authorization or with an appropriate court order. Alcohol and drug abuse treatment information is also subject to special protections under federal law. We will usually need to get your written authorization or an appropriate court order before we release this information. Except where there are special protections under Indiana law or other federal laws, we may use and disclose your Protected Health Information without your permission for the following purposes:
For treatment purposes. We may disclose your health information to doctors, nurses and others who provide your health care. For example, your information may be shared with people performing lab work or x-rays:
To obtain payment. We may disclose your health information in order to bill and collect payment for your health care treatment and services. For instance, we may release information to your insurance company, or we may provide limited portions of your health information to your health plan to get paid for the health care services we provide to you, unless you have paid for the health care service in full and specifically request us not to disclose information related to that service. We may also provide your health information to our business associates who assist us with billing, such as billing companies, claims processing companies, and others that process our health care claims. We will only disclose the minimum amount of information needed to obtain payment.
For health care operations. We may use or disclose your health information in order to perform business functions like employee evaluations and improving the service we provide. We may disclose your information to students training with us. We may also provide your health information to our auditors, attorneys, consultants, and others in order to make sure we are complying with the laws that affect us. We may use your information to contact you to remind you of your appointment or to call you by name in the waiting room when your doctor is ready to see you.
When required by law. We may be required to disclose your Protected Health Information to law enforcement officers, courts or government agencies. For example, we may have to report abuse, neglect or certain physical injuries.
For public health activities. We may be required to report your health information to government agencies to prevent or control disease or injury. We also may have to report work-related illnesses and injuries to your employer so that your workplace may be monitored for safety.
For health oversight activities. We may be required to disclose your health information to government agencies so that they can monitor or license health care providers such as doctors and nurses.
For or activities related to death. We may be required to disclose your health information to coroners, medical examiners and funeral directors so that they can carry out duties related to your death, such as determining the cause of death or preparing your body for burial. We also may disclose your information to those involved with locating, storing or transplanting donor organs or tissue.
For studies. In certain limited circumstances, we may provide health information in order to conduct medical research studies. Use of this information for research is subject to either a special approval process or removal of information which may directly identify you. In most instances, we will require your written authorization prior to using or disclosing health information for research purposes.
To avert a threat to health or safety. In order to avoid a serious threat to health or safety, we may disclose health information to law enforcement officers or other persons who might prevent or lessen that threat.
For specific government functions. In certain situations, we may disclose health information of military officers and veterans, to correctional facilities, to government benefit programs, and for national security reasons.
For workers' compensation purposes. We may disclose your health information to government authorities under workers' compensation laws.
For fundraising purposes. We may use certain information (such as demographic information, dates of services, department of service, treating physicians, and outcomes) to send fundraising communications to you. However, you may opt out of receiving any such communications by contacting our Privacy Officer (listed below) and your decision to opt-out will have no impact on your treatment.
Uses and Disclosures of Your Protected Health Information That Offer You an Opportunity to Object
In the following situations, we may disclose some of your Protected Health Information if we first inform you about the disclosure and you do not object:
In patient directories. Your name, location and general health condition may be listed in our patient directory for disclosure to callers or visitors who ask for you by name. Additionally, your religion may be shared with clergy.
To your family, friends or others involved in your care. We may share with these people information related to their involvement in your care or information to notify them as to your location or general condition. We may release your health information to organizations handling disaster relief efforts.
Uses and Disclosures of Your Protected Health Information That Require Your Consent
The following uses and disclosures of your Protected Health Information will be made only with your written permission, which you may withdraw at any time:
For research purposes. In order to serve our patient community, we may want to use your health information in research studies. For example, researchers may want to see whether your treatment cured your illness. In such an instance, we will ask you to complete a form allowing us to use or disclose your information for research purposes. Completion of this form is completely voluntary and will have no effect on your treatment.
For marketing purposes. Without your permission, we will not send you mail or call you on the telephone in order to urge you to use a particular product or service, unless such a mailing or call is part of your treatment. Additionally, without your permission we will not sell or otherwise disclose your Protected Health Information to any person or company seeking to market its products or services to you.
Of psychotherapy notes. Without your permission, we will not use or disclose notes in which your doctor describes or analyzes a counseling session in which you participated, unless the use or disclosure is for on-site student training, for disclosure required by a court order, or for the sole use of the doctor who took the notes.
For any other purposes not described in this Notice. Without your permission, we will not use or disclose your health information under any circumstances that are not described in this Notice.
Your Rights Regarding Your Protected Health Information
You have the following rights related to your Protected Health Information:
To inspect and request a copy of your Protected Health Information. In most cases, you have the right to look at or get copies of your health information that we have, but you must make the request in writing. You may not view or copy psychotherapy notes, information collected for use in a legal or government action, and information which you cannot access by law. If we use or maintain the requested information electronically, you may request that information in electronic format. If we do not have your health information but we know who does, we will tell you how to get it. We will respond to you within 30 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have the denial reviewed. If you request copies of your health information, we will charge you a reasonable fee as permitted by Indiana law. Instead of providing the health information you requested, we may provide you with a summary or explanation of the health information. We will only do this if you agree to receive information in that form and if you agree to pay the cost in advance.
To request that we correct your Protected Health Information. If you think that there is a mistake or a gap in our file of your health information, you may ask us in writing to correct the file. We may deny your request in writing if the health information is: 1) correct and complete; 2) not created by us; 3) not allowed to be disclosed, or 4) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file a statement of disagreement, you have the right to ask that your request and our denial be attached to all future disclosures of your health information. If we approve your request, we will make the change to your health information, tell you that we have done it, and tell others that need to know about the change to your health information.
To request a restriction on the use or disclosure of your Protected Health Information. You may ask us to limit how we use or disclose your information, but we generally do not have to agree to your request. An exception is that we must agree to a request not to send Protected Health Information to a health plan for purposes of payment or health care operations if you have paid in full for the related product or service. If we agree to all or part of your request, we will put our agreement in writing and obey it except in emergency situations. You may not limit the uses and disclosures that we are legally required to make.
To request confidential communication methods. You may ask that we contact you at a certain address or in a certain way. We must agree to your request as long as it is reasonably easy for us to do so.
To find out what disclosures have been made. You have the right to request a list of instances in which we have disclosed your health information. The list will not include uses or disclosures made for treatment, payment, and health care operation, or information given to your family or friends with your permission or in your presence without objection. It will also not include disclosures made directly to you or when you have given us a written authorization for the release of health information. The list will also not include information released for national security purposes or given to correctional institutions. To obtain this list, you must make a request in writing to the Privacy Officer listed at the bottom of this notice. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you upon request once each year at no charge.
To receive notice if your records have been breached. We will notify you if there has been an acquisition, access, use or disclosure of your Protected Health Information in a manner not allowed under the law and which we are required by law to report to you. We will review any suspected breach to determine the appropriate response under the circumstances.
To obtain a paper copy of this Notice. Upon your request, we will give you a paper copy of this Notice.
Changes to this Notice
We are required to abide by the terms of this Notice of Privacy Practices. However, we may change our notice at any time. The new notice will be effective for all protected health information maintained by us. A revised Notice of Privacy Practices will be posted at the main entrances to our covered healthcare provider areas, may be requested from the Privacy Officer listed at the bottom of this notice, and may be found on our website at: https://www.proteamtactical.com/notice-of-privacy-practice/
If you have any questions about these rights, please contact us.
How to Complain about Our Privacy Practices
If you think we may have violated your privacy rights, or if you disagree with a decision we made about your Privacy Practice, you can mail a complaint to our Director of Operations, Tim Drudge, 1531 E Northfield Drive, Suite 300, Brownsburg, IN 46112.
You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services by writing to 200 Independence Avenue SW, Washington, D.C. 20201 or by calling 1-877-696-6775.
We will not punish you or retaliate against you if you file a complaint about our privacy practices.
How to Receive More Information About our Privacy Practices
If you have questions about this Notice or about our privacy practices, please contact our Director of Operations, Tim Drudge (317) 804- 5301.
Effective Date
This Notice is effective on November 30, 2023.