NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW WILLIAM E. BENNETT, MD, MAY USE AND DISCLOSE YOUR HEALTHCARE INFORMATION AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

William E. Bennett, MD is required by law to maintain the privacy of your protected health information.  This information consists of all records related to your health, including demographic information, either created by William E. Bennett, MD or received by William E. Bennett, MD from other healthcare providers.

We are required to provide you with notice of our legal duties and privacy practices with respect o your protected health information. These legal duties and privacy practices are described in this Notice.  William E. Bennett, MD will abide by the terms of this Notice, or the Notice currently in effect at the time of the use or disclosure of your protected health information. ¹

William E. Bennett, MD reserves the right to change the terms of this Notice and to make any new provisions effective for all protected health information that we maintain.  Patients will be provided a copy of any revised Notices upon request.  An individual may obtain a copy of the current Notice from our office at any time.

Uses and Disclosures of Your Protected Health Information not Requiring Your Consent

William E. Bennett, MD may use and disclose your protected health information, without your written consent or authorization, for certain treatment, payment and healthcare operations.  There are certain restrictions on uses and disclosures of treatment records, which include registration and all other records concerning individuals who are receiving, or who at any time have received services for mental illness, developmental disabilities, alcoholism, or drug dependence.  There are also restrictions on disclosing HIV test results.

Treatment may include:

·          Providing, coordinating, or managing healthcare and related services by one or more healthcare providers;

·          Consultations between healthcare providers concerning a patient;

·          Referrals to other providers for treatment;

·          Referrals to nursing homes, foster care homes, or home health agencies.

For example, William E. Bennett, MD may determine that you require the services of a specialist.  In referring you to another doctor, William E. Bennett, MD may share or transfer your healthcare information to that doctor.

Payment activities may include:

·          Activities undertaken by William E. Bennett, MD to obtain reimbursement for services provided to you;

·          Determining your eligibility for benefits or health insurance coverage;

·          Managing claims and contacting your insurance company regarding payment;

·          Collection activities to obtain payment for services provided to you;

·          Reviewing healthcare services and discussing with your insurance company the medical necessity of certain services or procedures, coverage under your health plan, appropriateness of care, or justification of charges;

·          Obtaining pre-certification and pre-authorization of services to be provided to you.

For example, William E. Bennett, MD will submit claims to your insurance company on your behalf.  This claim identifies, you, your diagnosis, and the services provided to you.

Healthcare operations may include

·          Contacting healthcare providers and patients with information about treatment alternatives;

·          Conducting quality assessment and improvement activities;

·          Conducting outcomes evaluation and development of clinical guidelines;

·          Protocol development, case management, or care coordination;

·          Conducting or arranging for medical review, legal services, and auditing functions.

For example, William E. Bennett, MD may use your diagnosis, treatment, and outcome information to measure the quality of the services that we provide, or assess the effectiveness of your treatment when compared to patients in similar situations.

William E. Bennett, MD may contact you, by telephone or mail, to provide appointment reminders.  You must notify us if you do not wish to receive appointment reminders.

We may not disclose your protected health information to family members or friends who may be involved with your treatment or care without your written permission.  Health information may be release without permission to a parent, guardian, or legal custodian of a child; the guardian of an incompetent adult; the healthcare agent designate in an incapacitated patient’s healthcare power of attorney; or the personal representative or spouse of a deceased patient.

There are additional situations when William E. Bennett, MD is permitted or required to use or disclose your protected health information without our consent or authorization.  Examples include the following:

·          As permitted or required by law.

In certain circumstances we may be required to report individual health information to legal authorities, such as law enforcement officials, court officials, or government agencies.  For example, we may have to report abuse, neglect, domestic violence or certain physical injuries.  We are required to report gunshot wounds or any other wound to law enforcement officials if there is reasonable cause to believe that the wound occurred as a result of a crime.

Mental health records may be disclosed to law enforcement authorities for the purpose of reporting an apparent crime on our premises.

·          For public health activities.

We may release healthcare records, with the exception of treatment records, to certain government agencies or public health authority authorized by law, upon receipt of written request from that agency.  We are required to report positive HIV test results to the state epidemiologist.  We may also disclose HIV test results to other providers or persons when there are has been or will be risk of exposure.

We may report to the state epidemiologist the name of any person known to have been significantly exposed to a patient who tests positive for HIV.  We are required by law to report suspected child abuse and neglect and suspected abuse of an unborn child, but cannot disclose HIV results in connection with the reporting or prosecution of alleged abuse or neglect.  We may release healthcare records, including treatment records and HIV test results, to the Food and Drug Administration when required by federal law.  We may disclose healthcare records, except for HIV test results, for the purpose of reporting elder abuse or neglect, provided the subject of the abuse or neglect agrees, or if necessary to prevent serious harm.  Records may be released for the reporting of domestic violence if necessary to protect the patient or community from imminent and substantial danger.

·          For health oversight activities.

We may disclose healthcare records, including treatment records, in response to a written request by any federal or state governmental agency to perform legally authorized functions, such as management audits, financial audits, program monitoring and evaluating, and facility or individual licensure or certification.  HIV test results may not be released to federal or state government agencies, without written permission, except to the state epidemiologist for surveillance, investigation, or to control communicable diseases.

·          Judicial and Administrative Proceedings.

Patient healthcare records, including treatment records and HIV test results, may be disclosed pursuant to a lawful court order.  A subpoena signed by a judge is sufficient to permit disclosure of all healthcare records except for HIV test results.

·          For activities related to death.

We may disclose patient healthcare records, except for treatment records, to a coroner or medical examiner for the purpose of completing a medical certificate or investigating a death.  HIV test results may be disclosed under certain circumstances.

·          For research.

Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.

·          To avoid a serious threat to health or safety.

We may report a patient’s name and other relevant data to the Department of Transportation if it is believed the patient’s vision or physical or mental condition affects the patient’s ability to exercise reasonable or ordinary control over a motor vehicle.  Healthcare information, including treatment records and HIV test results, may be disclosed where disclosure is necessary to protect the patient or comminute from imminent and substantial danger.

·          For worker’s compensation.

We may disclose your health information to the extent such records are reasonably related to any injury for which workers compensation is claimed.

William E. Bennett, MD will not make any other use or disclosure of your protected health information without your written authorization.  You may revoke such an authorization at any time, except to the extent that William E. Bennett, MD has taken action in reliance thereon.  Any revocation must be made in writing.

Your Rights Regarding Your Protected Health Information

You are permitted to request that restrictions be placed on certain uses or disclosures of your protected health information by William E. Bennett, MD to carry out treatment, payment, or healthcare operations.  You must request such a restriction in writing.  We are not required to agree to your request, but if we do agree, we must adhere to the restriction, except when your protected health information is needed in an emergency treatment situation.  In this event, information may be disclosed only to healthcare providers treating you.  Also, a restriction would no apply when we are required by law to disclose certain healthcare information.

You have the right to review and/or obtain a copy of your healthcare records, with the exception of psychotherapy notes, or information compiled for use (or in anticipation for use) in a civil, criminal, or administrative action or proceeding.  William E. Bennett, MD may deny an access under other circumstances, in which case you have the right to have such a denial reviewed.  We may charge a reasonable fee for copying your records.

You may request that William E. Bennett, MD send protected health information, including billing information, to you by alternative means or to alternative locations.  You may also request that William E. Bennett, MD not send information to a particular address or location or contact you at a specific location, perhaps your place of employment.  This request must be submitted in writing.  We will accommodate reasonable requests by you.

You have the right to request that William E. Bennett, MD amend portions of your healthcare records, as long as such information is maintained by us.  You must submit this request in writing, and under certain circumstances the request may be denied.

You may request to receive an accounting of the disclosures of your protected health information made by William E. Bennett, MD for the six years prior to the date of the request, beginning with disclosures made after April 14, 2003.  We are not required, however, to record disclosures we make pursuant to a signed consent or authorization.

Any person or patient may file a complaint with William E. Bennett, MD and/or the Secretary of Health and Human Services if they believe their privacy rights have been violated.  To file a complaint with William E. Bennett, MD, please contact the Privacy Officer at the following:

                Teresa Sirmans

                William E. Bennett, MD

                415 Devonia Street

                Harriman, Tennessee 37854

                (865) 882-9775

It is the policy of William E. Bennett, MD that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance or violation of the privacy standards.

This Notice of Privacy Practices is effective April 14, 2003.

¹ This Notice is prepared in accordance with the Health Insurance Portability and Accountability Act, 45 C.F.R.