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.
This Notice of Privacy Practices applies to Protected Health Information associated with Group Health
Plans provided by Geist Center for Allergy, Asthma & Immunology, PC to its employees, its employee’s
dependents and, as applicable, retired employees. This Notice describes how Geist Center for Allergy,
Asthma & Immunology, PC, collectively we, us, or our practice may use and disclose Protected Health
Information to carry out payment and health care operations, and for other purposes that are permitted or
required by law.
We are required by the privacy regulations issued under the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”) to maintain the privacy of Protected Health Information and to
provide individuals covered under our group health plan with notice of our legal duties and privacy
practices concerning Protected Health Information. We are required to abide by the terms of this Notice so
long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as
necessary and to make the new Notice effective for all Protected Health Information maintained by us. If
we make material changes to our privacy practices, copies of revised notices will be mailed to all
policyholders then covered by the Group Health Plan. Copies of our current Notice may be obtained by
contacting Geist Center for Allergy, Asthma & Immunology, PC at the telephone number below.
Protected Health Information (“PHI”) means individually identifiable health information, as defined by
HIPAA, that is created or received by us and that relates to the past, present, or future physical or mental
health or condition of an individual; the provision of health care to an individual; or the past, present, or
future payment for the provision of health care to an individual; and that identifies the individual or for
which there is a reasonable basis to believe the information can be used to identify the individual. PHI
includes information of persons living or deceased.
The following categories describe different ways that we use and disclose PHI. For each category of uses
and disclosures we will explain what we mean and, where appropriate, provide examples for illustrative
purposes. Not every use or disclosure in a category will be listed. However, all of the ways we are
permitted or required to use and disclose PHI will fall within one of the categories.
Your Authorization – Except as outlined below, we will not use or disclose your PHI unless you have
signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing
except to the extent that we have taken action in reliance upon the authorization or that the authorization
was obtained as a condition of obtaining coverage under the group health plan, and we have the right, under
other law, to contest a claim under the coverage or the coverage itself.
Uses and Disclosures for Payment – We may make requests, uses, and disclosures of your PHI as
necessary for payment purposes. For example, we may use information regarding your medical procedures
and treatment to process and pay claims. We may also disclose your PHI for the payment purposes of a
health care provider or a health plan.
Uses and Disclosures for Health Care Operations – We may use and disclose your PHI as necessary for
our health care operations. Examples of health care operations include activities relating to the creation,
renewal, or replacement of your Group Health Plan coverage, reinsurance, compliance, auditing, rating,
business management, quality improvement and assurance, and other functions related to your Group
Family and Friends Involved in Your Care – If you are available and do not object, we may disclose
your PHI to your family, friends, and others who are involved in your care or payment of a claim. If you
are unavailable or incapacitated and we determine that a limited disclosure is in your best interest, we may
share limited PHI with such individuals. For example, we may use our professional judgment to disclose
PHI to your spouse concerning the processing of a claim.
Business Associates – At times we use outside persons or organizations to help us provide you with the
benefits of your Group Health Plan. Examples of these outside persons and organizations might include
vendors that help us process your claims. At times it may be necessary for us to provide certain of your
PHI to one or more of these outside persons or organizations.
Other Products and Services – We may contact you to provide information about other health-related
products and services that may be of interest to you. For example, we may use and disclose your PHI for
the purpose of communicating to you about our health insurance products that could enhance or substitute
for existing Group Health Plan coverage, and about health-related products and services that may add value
to your Group Health Plan.
Other Uses and Disclosures – We may make certain other uses and disclosures of your PHI without your
We may use or disclose your PHI for any purpose required by law. For example, we may be
required by law to use or disclose your PHI to respond to a court order.
We may disclose your PHI for public health activities, such as reporting of disease, injury, birth
and death, and for public health investigations
We may disclose your PHI to the proper authorities if we suspect child abuse or neglect; we may
also disclose your PHI if we believe you to be a victim of abuse, neglect, or domestic violence.
We may disclose your PHI if authorized by law to a government oversight agency (e.g., a state
insurance department) conducting audits, investigations, or civil or criminal proceedings.
We may disclose your PHI in the course of a judicial or administrative proceeding (e.g., to
respond to a subpoena or discovery request).
We may disclose your PHI to the proper authorities for law enforcement purposes.
We may disclose your PHI to coroners, medical examiners, and/or funeral directors consistent
We may use or disclose your PHI for cadaveric organ, eye or tissue donation.
We may use or disclose your PHI for research purposes, but only as permitted by law.
We may use or disclose PHI to avert a serious threat to health or safety.
We may use or disclose your PHI if you are a member of the military as required by armed forces
services, and we may also disclose your PHI for other specialized government functions such as
national security or intelligence activities.
We may disclose your PHI to workers' compensation agencies for your workers' compensation
We will, if required by law, release your PHI to the Secretary of the Department of Health and
Human Services for enforcement of HIPAA.
In the event applicable law, other than HIPAA, prohibits or materially limits our uses and disclosures of
Protected Health Information, as described above, we will restrict our uses or disclosure of your Protected
Health Information in accordance with the more stringent standard.
RIGHTS THAT YOU HAVE:
Access to Your PHI – You have the right of access to copy and/or inspect your PHI that we maintain in
designated record sets. Certain requests for access to your PHI must be in writing, must state that you want
access to your PHI and must be signed by you or your representative (e.g., requests for medical records
provided to us directly from your health care provider). Access request forms are available from Geist
Center for Allergy, Asthma & Immunology, PC at the address below. We may charge you a fee for copying
Amendments to Your PHI – You have the right to request that PHI that we maintain about you be
amended or corrected. We are not obligated to make all requested amendments but will give each request
careful consideration. To be considered, your amendment request must be in writing, must be signed by
you or your representative, and must state the reasons for the amendment/correction request. Amendment
request forms are available from us at the address below.
Accounting for Disclosures of Your PHI – You have the right to receive an accounting of certain
disclosures made by us of your PHI. Examples of disclosures that we are required to account for include
those to state insurance departments, pursuant to valid legal process, or for law enforcement purposes. To
be considered, your accounting requests must be in writing and signed by you or your representative.
Accounting request forms are available from us at the address below. The first accounting in any 12-month
period is free; however, we may charge you a fee for each subsequent accounting you request within the
same 12-month period.
Restrictions on Use and Disclosure of Your PHI – You have the right to request restrictions on certain of
our uses and disclosures of your PHI for insurance payment or health care operations, disclosures made to
persons involved in your care, and disclosures for disaster relief purposes. For example, you may request
that we not disclose your PHI to your spouse. Your request must describe in detail the restriction you are
requesting. We are not required to agree to your request but will attempt to accommodate reasonable
requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such
termination is appropriate. In the event of a termination by us, we will notify you of such termination. You
also have the right to terminate, in writing or orally, any agreed-to restriction. You may make a request for
a restriction (or termination of an existing restriction) by contacting us at the telephone number or address
Request for Confidential Communications – You have the right to request that communications
regarding your PHI be made by alternative means or at alternative locations. For example, you may request
that messages not be left on voice mail or sent to a particular address. We are required to accommodate
reasonable requests if you inform us that disclosure of all or part of your information could place you in
danger. Requests for confidential communications must be in writing, signed by you or your
representative, and sent to us at the address below.
Right to a Copy of the Notice – You have the right to a paper copy of this Notice upon request by
contacting us at the telephone number or address below.
Complaints – If you believe your privacy rights have been violated, you can file a complaint with us in
writing at the address below. You may also file a complaint in writing with the Secretary of the U.S.
Department of Health and Human Services in Washington, D.C., within 180 days of a violation of your
rights. There will be no retaliation for filing a complaint.
FOR FURTHER INFORMATION
If you have questions or need further assistance regarding this Notice, you may contact the Privacy Office
by writing to: Geist Center for Allergy, Asthma & Immunology, PC
This Notice is effective April 14, 2003.