Advanced
Sleep Medicine & Diagnostic Services,
Inc.
SUMMARY OF NOTICE OF PRIVACY
PRACTICES
The Notice of Privacy Practices covers
services provided to you by Advanced
Sleep Medicine & Diagnostic Services,
Inc.. We are required by
law to maintain the privacy of protected
health information and to provide you
with the Notice of our legal duties
and privacy practices with respect to
protected health information. “Protected
health information” is information
about you, including demographic information,
that may identify you and that relates
to your past, present or future physical
or condition and related health care
services.
The Notice describes how we may use
and disclose your protected health information
to carry out treatment, payment or health
care operations. Other uses and disclosures
of your protected health information
will be made only with your written
authorization, unless otherwise permitted
or required by law. The Notice also
describes your rights to access and
control your protected health information.
Further, the Notice informs you of your
rights to complain to us or Department
of Health and Human Services
if you believe your privacy rights have
been violated by us.
We are required to abide by the terms
of the Notice. We may change the terms
of our notice, at any time. The new
notice will be effective for all protected
health information that we maintain
at that time. Upon your request, we
will provide you with any revised Notice
accessing our website Our
website address is: AdvancedSleepMed.Com,
calling Giso Amery
and requesting that a revised copy be
sent to you in the mail, or asking for
one at the time of your next appointment.
Please read the attached Notice carefully.
Advanced Sleep Medicine
& Diagnostic Services, Inc.
NOTICE OF PRIVACY PRACTICES
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.
If you have any questions about this
Notice please contact: our Privacy Contact
who is
Giso Amery
We are required by law to maintain the
privacy of protected health information
and to provide you with this Notice
of our legal duties and privacy practices
with respect to protected health information.
“Protected health information”
is information about you, including
demographic information, that may identify
you and that relates to your past, present
or future physical or mental health
or condition and related health care
services.
We are required to abide by the terms
of this Notice currently in effect.
We may change the terms of our notice,
at any time. The new notice will be
effective for all protected health information
that we maintain at that time. Upon
your request, we will provide you with
any revised Notice by accessing our
website: AdvancedSleepMedCom,
calling our Privacy Contact and requesting
that a revised copy be sent to you in
the mail, or asking for one at the time
of your next appointment.
1.
USES AND DISCLOSURES OF PROTECTED HEALTH
INFORMATION
Uses and Disclosures of Protected
Health Information for Treatment, Payment,
or Operations
Your protected health information may
be used by your health care provider
for treatment, payment and health care
operations as described in this Section
1 without authorization from you. Your
protected health information may be
used and disclosed by your health care
provider, our office staff and others
outside of our office that are involved
in your care and treatment for the purpose
of providing health care services to
you. Your protected health information
may also be used and disclosed to pay
your health care bills and to support
the operation of the health care provider’s
practice.
Following are examples of the types
of uses and disclosures of your protected
health care information that the health
care provider’s office is permitted
to make without your specific authorization.
These examples are not meant to be exhaustive,
but to describe the types of uses and
disclosures that may be made by our
office.
Treatment: We
will use and disclose your protected
health information to provide, coordinate,
or manage your health care and any related
services. This includes the coordination
or management of your health care with
a third party, consultations with another
health care provider, or your referral
to another health care provider for
your diagnosis and treatment. For example,
we would disclose your protected health
information, as necessary, to a home
health agency that provides care to
you.
Payment: Your
protected health information will be
used, as needed, to obtain or provide
payment for your health care services,
including disclosures to other entities.
This may include certain activities
that your health insurance plan may
undertake before it approves or pays
for the health care services we recommend
for you such as making a determination
of eligibility or coverage for insurance
benefits, reviewing services provided
to you for medical necessity, and undertaking
utilization review activities. For example,
obtaining approval for a hospital stay
may require that your relevant protected
health information be disclosed to the
health plan to obtain approval for the
hospital admission.
Healthcare Operations:
We may use or disclose, as needed, your
protected health information in order
to support the business activities of
your health care provider’s practice.
These activities include, but are not
limited to: quality assessment and improvement
activities; reviewing the competence
or qualifications of health care professionals;
training of sleep technicians, medical
students/and or any training related
to sleep within this entity; securing
stop-loss or excess of loss insurance;
obtaining legal services or conducting
compliance programs or auditing functions;
business planning and development; business
management and general administrative
activities, such as compliance with
the Health Insurance Portability and
Accountability Act; resolution of internal
grievances; due diligence in connection
with the sale or transfer of assets
of your health care provider’s
practice; creating de-identified health
information; and conducting or arranging
for other business activities.
For example, we may disclose your protected
health information to medical school
students and or sleep student/trainee
technicians that see patients at our
office. In addition, we may use a sign-in
sheet at the registration desk where
you will be asked to sign your name
and your arrival time. We may also call
you by name in the waiting room when
your treating provider is ready to see
you. We may use or disclose your protected
health information, as necessary, to
contact you to remind you of your appointment,
or to discuss disease management or
wellness programs with you.
We will share your protected health
information with third party “business
associates” that perform various
activities (e.g., billing, transcription
services, accounting services, legal
services, IT services, laboratory, home
healthcare agencies, accreditation organizations,
collection agencies, for the practice.
Whenever an arrangement between our
office and a business associate involves
the use or disclosure of your protected
health information, we will have a written
contract that contains terms that will
protect the privacy of your protected
health information.
We may use or disclose your protected
health information, as necessary, to
provide you with information about a
product or service to encourage you
to purchase or use the product or services
for the following limited purposes:
(1) to describe our participation in
a health care provider network or health
plan network, or to describe if, and
the extent to which, a product or service
(or payment for such product or service)
is provided by our practice or included
in a plan of benefits; (2) for your
treatment; or (3) for your case management
or care coordination, or to direct or
recommend alternative treatments, therapies,
health care providers, or settings of
care.
In addition, we may disclose your protected
health information to another provider,
health plan, or health care clearinghouse
for limited operational purposes of
the recipient, as long as the other
entity has, or has had, a relationship
with you. Such disclosures shall be
limited to the following purposes: quality
assessment and improvement activities,
case management, conducting training
programs, accreditation, certification,
licensing, credentialing activities,
and health care fraud and abuse detection
and compliance programs.
Uses and Disclosures of Protected
Health Information Based upon Your Written
Authorization
Other uses and disclosures of your protected
health information will be made only
with your written authorization, unless
otherwise permitted or required by law.
You may revoke this authorization, at
any time, in writing, except to the
extent that your health care provider
or the provider’s practice has
taken an action in reliance on the use
or disclosure indicated in the authorization.
2.
YOUR RIGHTS
Following is a statement of your rights
with respect to your protected health
information and a brief description
of how you may exercise these rights.
You have the right to inspect
and copy your protected health information.
This means you may inspect and obtain
a copy of protected health information
about you that is contained in a designated
record set for as long as we maintain
the protected health information. A
“designated record set”
contains medical and billing records
and any other records that your health
care provider and the practice uses
for making decisions about you.
Under federal law, however, you may
not inspect or copy the following records:
psychotherapy notes; information compiled
in reasonable anticipation of, or use
in, a civil, criminal, or administrative
action or proceeding; and protected
health information that is subject to
law that prohibits access to protected
health information. Depending on the
circumstances, a decision to deny access
may be reviewable. In some circumstances,
you may have a right to have this decision
reviewed. Please contact our Privacy
Contact if you have questions about
access to your medical record.
You have the right to request
a restriction of your protected health
information. This means
you may ask us not to use or disclose
any part of your protected health information
for the purposes of treatment, payment
or healthcare operations. You may also
request that any part of your protected
health information not be disclosed
to family members or friends who may
be involved in your care or for notification
purposes as described in this Notice.
Your request must state the specific
restriction requested and to whom you
want the restriction to apply.
Your health care provider is not required
to agree to a restriction that you may
request. If your health care provider
believes it is in your best interest
to permit use and disclosure of your
protected health information, your protected
health information will not be restricted.
If your health care provider does agree
to the requested restriction, we may
not use or disclose your protected health
information in violation of that restriction
unless it is needed to provide emergency
treatment. With this in mind, please
discuss any restriction you wish to
request with your health care provider.
You may request for special restrictions
form verbally or in writing, once we
receive the appropriate form necessary
steps will be taken by our privacy officer.
You have the right to request
to receive confidential communications
from us by alternative means or at an
alternative location. We
will accommodate reasonable requests.
We may also condition this accommodation
by asking you for information as to
how payment will be handled or specification
of an alternative address or other method
of contact. We will not request an explanation
from you as to the basis for the request.
Please make this request in writing
to our Privacy Officer.
You may have the right to
have your provider amend your protected
health information. This
means you may request an amendment of
protected health information about you
in a designated record set for as long
as we maintain this information. In
certain cases, we may deny your request
for an amendment. If we deny your request
for amendment, you have the right to
file a statement of disagreement with
us and we may prepare a response to
your statement and will provide you
with a copy of any such response. Please
contact our Privacy Officer to determine
if you have questions about amending
your medical record.
You have the right to receive
an accounting of certain disclosures
we have made, if any, of your protected
health information. This
right applies to disclosures for purposes
other than treatment, payment or healthcare
operations as described in this Notice.
It excludes disclosures we may have
made to you, for a facility directory
(if applicable), to family members or
friends involved in your care, or for
notification purposes, or disclosures
for which you have signed an authorization.
You have the right to receive specific
information regarding these disclosures
that occurred after April 14, 2003.
You may request a shorter timeframe.
The right to receive this information
is subject to certain exceptions, restrictions
and limitations.
You have the right to obtain
a paper copy of this Notice from us,
upon request, even if you have agreed
to accept this Notice electronically.
3.
COMPLAINTS
You may complain to us or to the Department
of Health and Human Services if you
believe your privacy rights have been
violated by us. You may file a complaint
with us by notifying our Privacy Officer
of your complaint. We will not retaliate
against you for filing a complaint.
You may contact our Privacy officer,
Giso Amery at
(818) 817-2621
for further information about the complaint
process.
This Notice was published and becomes
effective on April 14, 2003.
