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Interventional Cardiovascular Associates, P.A.
20 Prospect Avenue
Suite 503
Hackensack, NJ 07601
Tel: 201.996.1444

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW PATIENT HEALTH INFORMATION (PHI) MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. However we will inform you of that change if and when it does occur. The new notice would be effective for all protected health information that we maintain.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED ON YOUR CONSENT

You will be asked by either Interventional Cardiovascular Associates, P.A., in Hackensack or Paramus to sign a consent/acknowledgment form. By signing the consent/acknowledgment form, our office staff and physicians, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you may also use and disclose you PHI (Protected Health Information) to pay your health care bills and to support the operation of the physicians' office.

The following are examples of the types of uses and disclosures of your PHI (Protected Health Information) that the office is permitted to make once you have signed our consent/acknowledgment form.

Treatment We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This information may be disclosed to nurses, technicians, medical students, and other office personnel. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your PHI. This also allows for the disclosure of your PHI to people outside the office who may be involved in your care after you leave our office, such as a family member of clergy.

Payment Your PHI will be used, as needed, to obtain payment for your health care services. This may include, but is not limited to, certain activities that your health insurance plan may undertake before it approves or pays for the health care services that 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. This also allows for the disclosure of your PHI to hospitals, ambulatory surgery centers, nursing homes, imaging centers or any other setting that may be billed to you and payment may be collected from you, your insurance company or any other responsible third party.

Health Care Operations We may use and disclose, as needed, your PHI in order to support the business activities and to maintain quality care. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fund-raising activities, and conducting or arranging for other business activities. For example: we may use medical information to review treatment and services and to evaluate the performance of our staff in the care of you. We may also combine medical information about many office patients to decide what additional services the office could offer, what other services are needed and whether certain new treatments are effective. We may also need to disclose information to doctors, nurses, technicians, and other offices personnel at other facilities. In addition, we may use a sign in sheet at the front window/ slash registration area where you will be asked to sign your name. We may also call you by name in the waiting room when the physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you either by US mail, email, fax or telephone to remind your of your appointment, and if asked the nature of said appointment. This also allows us to disclose your PHI to any and all family members or those that you deem necessary either to have your PHI either faxed, sent via mail or email, or seated with you in the examination room.

Treatment Alternatives We may use and disclose PHI to relate to you possible treatment options that may be of interest to you regarding your health care.

Health Related Benefits and Services We may use and disclose PHU to help you benefit from services that would be of interest.

Research Under certain circumstances, we may use or disclose PHI for research purposes. For example, a research project may involve comparing the health and recovery of all patients who have received one medication to those who have received another medication for the same condition. All research projects, however, are subject to a special approval process. Before we use or disclose medical information for research, the project will have to be approved through a standard research approval process. We will almost always ask for your specific permission if the research will have access to your name, address or other information that reveals who you are.

Others Involved in Your Healthcare Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, PHI that directly relates to that person['s involvement in your health care. If you are unable to agree to object to such disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgement. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, general condition or death. Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals in your health care.

To Avert a Serious Threat to Health or Safety We may use and disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Organ and Tissue Donations If you are an organ donor, we may release medical information to an organization that handles organ procurement, organ, eye or tissue transplantation or to an organ donation bank, as necessary.

Workers' Compensation We may release PHI to workers' compensation or similar programs. These programs provide benefits for work related injuries or illnesses.

Public Health Risks We may disclose PHI for public health activities. These activities generally include the following:

  • To prevent or control disease, injury or disability.
  • To report births or deaths.
  • To report child abuse or neglect
  • To report reactions to medications or problems with products.
  • To notify people of products being recalled that they may be using.
  • To notify a person who may have been exposed to a disease or may at risk for contracting or spreading a disease or condition.
  • To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence We will only make this disclosure if you agree or when required by law.

Health Oversight Activities We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.

Law Enforcement We may release medical information if requested by a law-enforcement official acting pursuant to valid legal authority.

Coroners, Medical Examiners and Funeral Directors We may release medical information to a coroner or medical examiner. The may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities We may release PHI to authorized federal officials for intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for the purpose of determining your own security clearance and other national security activities authorized by law.

Inmates If you are an inmate of a correctional facility or under the custody of a law enforcement official, we may release PHI to the correctional institution or law enforcement official.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

Right to Inspect and Copy You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Interventional Cardiovascular Associates, P.A.

Interventional Cardiovascular Associates, P.A. may deny your request to inspect and copy in certain limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the office will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend If you feel that medical information we have bout you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the office.

To request an amendment, your request must be made in writing and submitted to Interventional Cardiovascular Associates, P.A., Attention Privacy Officer. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for the office;
  • Is not part of the information you would be permitted to inspect and copy or
  • Is accurate and complete.

Right to an Accounting Disclosure You have the right to request an "accounting of disclosures." This is alist of the disclosures we made regarding PHI. To request this list or accounting of disclosures, you must submit your request in writing to Interventional Cardiovascular Associates, P.A. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. We will notify you of the cost involved and you may choose to withdraw to modify your request at that time before any costs are incurred.

Right to Request Restrictions You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care of the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Interventional Cardiovascular Associates, P.A. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure our both; and (3) to whom you want he limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communication You have the right to request hat we communicate with you about medical matters in a certain way or at a certain location. For example you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to Interventional Cardiovascular Associates, P.A. Privacy Officer. We will accommodate all "reasonable" requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.

Changes To This Notice We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future.

Complaints If you believe your privacy rights have been violated, you may file a complaint with the office or with the Secretary of the Department of Health and Human Services. To file a complaint with the office, you contact Lynne Kohlmann, Practice Administrator at 201-996-1444. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses Of Medical Information Other used and disclosures of medical information not covered by this notice r the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose PHI, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose PHI for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Patient Acknowledgment Our Notice of Privacy Practices provides information about how we may use and disclose Protected Health Information about you. You have the right to review our Notice and ask questions about our privacy practices. The terms of our Notice may change and be revised. If we change our Notice, you may obtain a revised copy by requesting one verbally or in writing.

You have the right to request that we restrict how Protected Health Information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

By signing this form you acknowledge that you have received our Notice of Privacy Practices.

___________________________________
Name of Patient

______________________
D.O.B.

____________________________________
Patient's Signature

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Date

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