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This notice describes how medical information about you may be
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.
When it comes to your health information, you have certain righ
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. • We will say “yes” to all reasonable requests. Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. • We are not required to agree to your request, and we may say “no” if it would affect your care. • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. • We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting us using the information on page 1. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. • We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices ab
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation • Include your information in a hospital directory • Contact you for fundraising efforts (If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.) In these cases we never share your information unless you give us written permission: • Marketing purposes • Sale of your information • Most sharing of psychotherapy notes In the case of fundraising: • We may contact you for fundraising efforts, but you can tell us not to contact you again.
How do we typically use or share your health information? We ty
How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you • We can use your health information and share it with other professionals who are treating you. (Example: A doctor treating you for an injury asks another doctor about your overall health condition.) Run our organization • We can use and share your health information to run our practice, improve your care, and contact you when necessary. (Example: We use health information about you to manage your treatment and services.) Bill for your services • We can use and share your health information to bill and get payment from health plans or other entities. (Example: We give information about you to your health insurance) How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues • We can share health information about you for certain situations such as: Preventing disease, Helping with product recalls, Reporting adverse reactions to medications, Reporting suspected abuse, neglect, or domestic violence, Preventing or reducing a serious threat to anyone’s health or safety Do research • We can use or share your information for health research. Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests • We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director • We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests • We can use or share health information about you: For workers’ compensation claims, For law enforcement purposes or with a law enforcement official, With health oversight agencies for activities authorized by law, For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions • We can share health information about you in response to a court or administrative order, or in response to a subpoena.
• We are required by law to maintain the privacy and security o
• We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of This Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Compliance Officer: Dr. Jeffrey Baron Compliance Manager:
Compliance Officer: Dr. Jeffrey Baron Compliance Manager: Miriam Acevedo Phone: 520-784-6102 Compliance Line: 520-784-6366 www.tucsonortho.com
Tucson Orthopaedic Institute complies with applicable Federal c
Tucson Orthopaedic Institute complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Tucson Orthopaedic Institute does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Tucson Orthopaedic Institute: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, please ensure your scheduler or check-in person is aware and assistance will be provided. You may also contact the office manager at your office location for further assistance. East Office 5301 E. Grant Road Tucson, AZ 85714 520-784-6200 Green Valley Office 495 W. Continental Road Green Valley, AZ 85614 520-382-8200 If you believe that Tucson Orthopaedic Institute has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Compliance Manager at 5301 East Grant Road, Tucson AZ 85714 or by phone at (520) 784-6366. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Compliance Manager is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201; or 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. ATTENTION: If you require language assistance services, we can assist you: (520)784-6366 - Compliance Manager or the Office Manager Spanish: ATENCIÓN: Si necesita servicios de asistencia con el idioma, comuníquese con nuestro Gerente de Cumplimiento. Navajo: ATENCIÓN: Si necesita servicios de asistencia con el idioma, comuníquese con nuestro Gerente de Cumplimiento. Chinese: 注意:如果您需要語言幫助服務, 請聯繫我們的合規經理 Vietnamese: LƯU Ý: Nếu bạn yêu cầu dịch vụ hỗ trợ ngôn ngữ, vui lòng liên hệ với Người quản lý tuân thủ của chúng tôi Arabic: تنبيه: إذا كنت بحاجة إلى خدمات المساعدة اللغوية ، فيرجى الاتصال بمدير الامتثال لدينا Turkish: DİKKAT: Dil yardımı hizmetlerine ihtiyacınız varsa, lütfen Uyumluluk Yöneticimizle iletişime geçin. Korean: 주의 : 언어 지원 서비스가 필요한 경우 준수 관리자에게 문의하십시오.
French: ATTENTION: si vous avez besoin de services d'assistance
French: ATTENTION: si vous avez besoin de services d'assistance linguistique, veuillez contacter notre responsable de la conformité German: ACHTUNG: Wenn Sie Sprachunterstützungsdienste benötigen, wenden Sie sich bitte an unseren Compliance Manager Russian: ВНИМАНИЕ: Если вам требуются услуги языковой поддержки, свяжитесь с нашим менеджером по соблюдению нормативных требований. Japanese: 注意:言語支援サービスが必要な場合は、コンプライアンスマネージャーにお問い合わせください Persian: توجه: اگر به خدمات كمك زبان نياز داريد ، با مدير انطباق ما تماس بگيريد Serbian: ПАЖЊА: Ако су вам потребне услуге језичке помоћи, контактирајте нашег менаџера за усаглашеност Thai: ความสนใจ: หากคุณต้องการบริการช่วยเหลือด้านภาษาโปรดติดต่อผู้จัดการการปฏิบัติตามกฎระเบียบของเรา
Northwest Office 6320 N. La Cholla Blvd., #200 Tucson, AZ 85741
Northwest Office 6320 N. La Cholla Blvd., #200 Tucson, AZ 85741 520-382-8200 Rincon Clinic 10350 E. Drexel Road, #210 Tucson, AZ 85747 520-784-6200
Oro Valley Office 12315 N. Vistos Park Road Oro Valley, AZ 857
Oro Valley Office 12315 N. Vistos Park Road Oro Valley, AZ 85755 520-382-8200 Silverbell Clinic 8275 N. Silverbell Road, #113 Marana, AZ 85743 520-382-8200
St. Mary’s Office 395 N. Silverbell Road Tucson, AZ 85745 520-3
St. Mary’s Office 395 N. Silverbell Road Tucson, AZ 85745 520-382-8200 Sunrise at the Fit 4001 E. Sunrise Drive, #121 Tucson, AZ 85718 520-784-6200
NOTICE OF NONDISCRIMINATION
NOTICE OF NONDISCRIMINATION
CONFIDENTIALITY It is the policy of Tucson Orthopaedic Institut
CONFIDENTIALITY It is the policy of Tucson Orthopaedic Institute, Inc. to treat all patient information confidentially. This includes patient records and conversations. We will investigate any reported violation of this policy. If you have any questions, please ask a front desk representative for information. Tucson Orthopaedic Institute, Inc. makes every effort to provide our patients with an environment, which is safe, private, and respectful of our patient’s needs. If you have a complaint about our services, facilities, or staff, we want to hear from you. We will do everything we can to see that your experience with us is professional in every way. ISSUES OF CARE Tucson Orthopaedic Institute, Inc. is committed to your participation in care decisions. As a client, you have the right to ask questions and receive answers regarding the course of clinical care recommended by any of our health providers, including discontinuing care. We urge you to follow the healthcare directions given to you by our providers. However, if you have any doubts or concerns, or if you question the care prescribed by our providers, please ask. Each patient has the right to: • Receive quality health care. • Obtain a copy of this patient rights and responsibilities policy. • The patient has the right to courtesy, respect, dignity, responsiveness, and timely attention to his or her needs, regardless of race, religion, ethnic or national origin, gender, age, sexual orientation, or disability. • Confidentiality and privacy concerning medical care, communications, records, and related information, as provided by law and consistent with the needs of the involved providers to share information and monitor the quality of care; exceptions may include suspected abuse, public health hazards, and other instances when reporting is permitted or required by law. • Be fully informed of any experimental, research or educational programs that may be used in treatment, and to allow or refuse any such programs at any time without penalty. • Receive a prompt, considerate response to any question, complaint, or request for service that is within TOI’s ability, purpose, and duty to deliver. • Present a compliment or complaint to TOI and receive a response about any aspect of the patient’s care or treatment; presentation of a complaint will not compromise the patient’s access to care or the quality of future service. • Be informed of the diagnosis, treatment, and prognosis in easily understood language; make decisions about the patient’s plan of care, including the refusal of the treatment, and be informed of the consequences of these decisions. • An explanation about fees and payment plans, regardless of the source of payment • Have someone the patient chooses help make decisions about the patient’s care, with the understanding that TOI will honor this choice to the extent allowed by law. • Know the name and professional status of the persons providing care and know if TOI has relationships with outside parties that could influence treatment and care of the patient; these relationships may be with educational institutions, other health care providers, or insurers. • Expect TOI to be a safe environment. • Have access to a doctor on call 24 hours a day. • Review records pertaining to the patient’s care at TOI, and to have the information explained or interpreted as necessary, except when restricted by law. • Receive information about procedures, treatment, risks, and alternatives before giving consent for diagnosis or treatment. • Have the right to continuity of health care. The health provider has an obligation to cooperate in the coordination of medically indicated care with other health providers treating the patient. The health provider may discontinue care provided they give the patient reasonable assistance and direction, and sufficient opportunity to make alternative arrangements. Each patient has the responsibility to: • Participate actively in your health care and ask questions of health care providers and staff when an examination, technique, diagnosis or prescribed treatment is not understood. • Provide your health care provider with accurate information about medical history and other matters related to your health such as past illnesses, hospitalizations, and medications. • Keep appointment times and if not possible to do so, cancel appointments at least 24 hours in advance. • Satisfy the financial obligations to TOI promptly; this responsibility includes asking questions concerning your financial obligations, providing information necessary for insurance processing, and arranging for prompt payment. • Follow the treatment plan prescribed and promptly notify the health care provider of any changes in health status. • Be considerate and respectful of other patients and TOI personnel, and see that your companions are considerate as well. • Observe TOI policies and the rights of its personnel and other patients.
PATIENT RIGHTS AND RESPONSIBILITIES
PATIENT RIGHTS AND RESPONSIBILITIES
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