Notice of Privacy Practices (Revised 9-2013)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. WE ARE REQUIRED BY LAWS TO HAVE YOU SIGN AN ACKNOWLEDGEMENT FORM THAT YOU HAVE RECEIVED OR HAVE OPPORTUNITY TO RECEIVE OUR NOTICE OF PRIVACY PRACTICE. PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of
MIMI LEE, MD, PA. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.
Designation of a Personal Representative. A personal representative may be designated by you who may act on your behalf for the purposes of authorizing use and disclosure of protected health information, or receiving information that otherwise would be sent to you the patient (medical and financial). A personal representative may be the spouse, adult child, other members of your family, or close personal friend. You may designate a personal representative in writing on the acknowledgement form. Please notify our receptionist to list your personal representative. We will not be able to discuss any of your information (such as medical or billing information) unless the person is designated or listed by you in advance.
Additional Use of Your Information
Appointment reminders. Your health information will be used by our staff to send you appointment reminders.
Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may find interesting.
As an expert clinician, Dr. Lee may use your health information to provide training and educational activities.
In some cases, we may ask to use your photos for marketing and/or educational activities but your full name will never be used with the photos. You will also have the opportunity to approve the photos to be used.
We may also send you information describing other health-related products and services that we believe may interest you.
Fundraising. Unless you request us not to, we will use your name and address to support our fund-raising efforts. If you do not want to participate in fund-raising efforts, please check off the following box and inform our receptionist.
❑ Please do not use my information for fund-raising purposes.
Marketing. Unless you request us not to, there are some marketing activities for which we may use your name and address, to provide you with information about services and promotions available at our practice. If you’d rather not receive marketing communication from our practice, please check off the following box and inform our receptionist:
❑ Please do not use my information for marketing purposes
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purposes other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.
Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes when financial remuneration is involved. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.
You have certain rights under the federal privacy standards. These include:
The right to request restrictions on the use and disclosure of your protected health information if the request will not impede treatment, payment, or day-to-day functioning of the practice
The right to receive confidential communications concerning your medical condition and treatment. All requests must be made in writing and you must provide an alternative address or telephone number at which you may be contacted.
The right to inspect and copy your protected health information. All requests must be submitted in writing and there is a fee for copying.
The right to amend or submit corrections to your protected health information
The right to receive an accounting of how and to whom your protected health information has been disclosed
The right to receive a printed copy of this notice
MIMI LEE, MD, PA Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices outlined in this notice. In the event of a breach of unsecured protected health information, if your information has been compromised it is our duty to notify you.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.
Requests to Inspect Protected Health Information
You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting our receptionist or our privacy officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.
Questions / Comments / Complaints
If you would like to submit a comment or complaint or if you need further information about our privacy practices, you can do so by sending a letter outlining your concerns to our privacy officer below.
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the address below. You will not be penalized or otherwise retaliated against for filing a complaint.
Mimi Lee, MD, PA
Pavilion Centre, 8315 Cantrell Road, Suite 130
Little Rock, AR 72227
Effective date: 9-23-2013