Federal and state law provides you with certain basic rights and
protections in connection with the medical information we maintain
about you. "Arise Prosthetics" is required by law to
maintain the privacy of your medical information and to provide
you with notice of its legal duties and privacy practices with
respect to your medical information. This notice summarizes your
rights and Arise Prosthetics' duties with respect to your medical
information. It also describes how Arise Prosthetics' personnel
may use and disclose your medical information. Finally, it describes
the complaint process for you to follow if you believe your privacy
rights have been violated. If you have any questions about this
notice or your rights relating to your medical information, please
contact Arise Prosthetics' Privacy Officer at (602) 864-5560.
You have the following rights regarding medical information we
maintain about you:
A. Right to Inspect
and Copy. You
have the right to inspect and copy medical information about you-
Usually, this includes medical and billing records, but does not
include psychotherapy notes.
To inspect and copy medical information about you, you must submit
your request in writing to Arise Prosthetics' Privacy Officer
at 1830 West Colter, Suite 101, Phoenix, AZ 85015. If you request
a copy of your medical information, we may charge a fee for the
costs of copying, mailing and other supplies associated with your
request.
We may deny all or part of your request to inspect and copy your
medical information in certain very limited circumstances. If
you are denied access to your medical information, you may, under
certain circumstances, request that such denial be reviewed. Any
such review will be conducted by a licensed health care professional
chosen by Arise Prosthetics; however, the person conducting the
review will not be the person who denied your request. We will
comply with the outcome of the review.
B. Right to Amend.
If you feel
that any of the medical information we have about you is incorrect
or incomplete you may ask us to amend such information. You have
the right to request an amendment for as long as the information
is kept by or for us.
To request an amendment, your request must be made in writing
and submitted to Arise Prosthetics' Privacy Officer at 1830 West
Colter, Suite 101, Phoenix, AZ 85015. 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
Arise Prosthetics:
· Is not part of the information which you would be permitted
to inspect and copy; or
· Is accurate and complete.
If we deny the requested amendment, you have the right to submit
a written statement disagreeing with the denial or, alternatively,
you may request Arise Prosthetics to provide your request for
amendment and the denial with any future disclosures of the information.
C. Right to an Accounting of Disclosures. You have the
right to receive an accounting of certain disclosures of your
medical information made by us in the six year prior to the date
on which the accounting is requested, starting from April 14,
2003 (the compliance date of the HIPAA Privacy Standards). Such
right to accounting, however, does not extend to disclosures made
to you, pursuant to an authorization, incident to a use or disclosure
otherwise permitted or required, for treatment, payment and health
care operations, for the patient directory, to family members
or friends involved in your care, for notification purposes, for
national security or intelligence purposes, to correctional institutions
or law enforcement officials in custodial situations, or as part
of a limited data set in accordance with applicable law.
To request an accounting of disclosures to which you are entitled,
you must submit your request in writing to Arise Prosthetics'
Privacy Officer at Arise Prosthetics LLC, 1830 West Colter, Suite
101, Phoenix, AZ 85015. Your request must state a time period
which may not be longer than six years and may not include dates
before April 14, 2003. Your request should indicate in what form
you want the list (for example, on paper, electronically). The
first list you request within any consecutive 12 month period
will be free. For additional lists, we may charge you for the
costs associated with providing the list. If we intend to charge
a fee, we will notify you of the estimated cost involved and will
give you an opportunity to withdraw or modify your request before
any costs are incurred.
D. Right to Request Restrictions. You have the right to
request restrictions or limitations 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 or the payment for your care, like a family
member or friend. For example, you could ask that we not use or
disclose information to a relative about a surgery you had.
Although 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. A restriction agreed
to by Arise Prosthetics is not effective to prevent uses or disclosures
permitted or required under Section 111. A below (excluding treatment,
payment, and health care operations).
Your request for restrictions should be made in writing to Arise
Prosthetics' Privacy Officer at Arise Prosthetics LLC, 1830 West
Colter, Suite 101, Phoenix, AZ 85015. In your request, you should
tell us (1) what information you want to limit: (2) whether you
want to limit our use, disclosure or both; and (3) to whom you
want the limits to apply (for example, disclosures to your spouse,
relative, etc.).
E. Right to Request Confidential Communications. You have
the right to request that 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. Any such
request must be made in writing to Arise Prosthetics' Privacy
Officer at Arise Prosthetics LLC, 1830 West Colter, Suite 101,
Phoenix, AZ 85015, and must specify how or where you wish to be
contacted. We will not ask you the reason for your request and
will accommodate all reasonable requests.
F. Right to Receive a Copy of This Notice. You have the
right to receive a paper copy of this notice. You may ask us to
give you a copy of this notice at any time. Even if you have agreed
to receive this notice electronically, you are still entitled
to a paper copy of this notice. You may obtain a copy of this
notice at our Website, www.ariseprosthetics.com or by contacting
Arise Prosthetics' Privacy Officer at 1830 West Colter, Suite
101, Phoenix, AZ 85015.
A. Uses and Disclosures of Medical Information That Do Not
Require Your Consent or Authorization. Following are examples
of the types of uses and disclosures of your protected medical
information that Arise Prosthetics is permitted or required by
law to make without your consent or authorization.
· Treatment. To provide you with medical treatment or services, we may need to use or disclose information about you to doctors, nurses, technicians, medical students or other Arise Prosthetics personnel who are involved in your treatment. For example, a doctor may need to know what drugs you are allergic to before prescribing medications. Departments within Arise Prosthetics may share medical information about you to coordinate your care. For instance, the laboratory may request information to complete lab work. We may also disclose medical information about you to people who may be involved in your medical care after you leave Arise Prosthetics, such as home health agencies, your family and clergy members.
· Payment We may use and disclose your medical information for Arise Prosthetics to bill and receive payment for the treatment that you received here. For example; we may use or disclose your medical information to your insurance company about a service you received at Arise Prosthetics so that your insurance company can pay us or reimburse you for the service. We may also ask your insurance company for prior authorization for a service to determine whether the insurance company will cover it.
· Health
Care Operations: We
may use and disclose medical information about you for our internal
operations. These include uses and disclosures that are necessary
to run Arise Prosthetics and make sure that our patients receive
quality care. For example. we may use or disclose medical information
about you to evaluate our staff's performance in caring for you.
Medical information about you and other patients may also be combined
to allow us to evaluate whether we should offer additional services
or discontinue other services and whether certain treatments are
effective. We may also compare this information with other health
care providers to evaluate whether we can make improvements in
the care and services that we offer. To best protect your privacy
when we are combining medical information we will remove information
that identifies you.
· Required
By Law: We
may use or disclose your medical information to the extent that
the use or disclosure is required by law. The use or disclosure
will be made in compliance with the law and will be limited to
the relevant requirements of the law.
· Public
Health: We
may disclose your protected medical information for public health
activities and purposes to a public health authority that is permitted
by law to collect or receive the information for the purpose of
preventing or controlling disease, injury or disability (e.g.,
reporting of disease, injury; vital elements such as birth or
death; public health surveillance or investigations, etc.). We
may also use or disclose your medical information, if directed
by the public health authority, to an official of a foreign government
agency that is collaborating with the public health authority.
· Food and
Drug Administration: We
may disclose your medical information to a person/company subject
to the jurisdiction of the U.S. Food and Drug Administration (FDA)
with respect to an FDA-regulated product or activity for which
that person/company has responsibility, for the purpose of the
activities related to the quality, safety or effectiveness of
such product or activity. Such purposes include to collect or
report adverse events, product defects or problems, or biologic
product deviations; to track FDA-regulated products: to enable
product recalls, repairs or replacement, or lookback (including
locating and notifying individuals who have received such products):
or to conduct post marketing surveillance.
· Communicable
Diseases: We
may disclose your medical information, if authorized by law, to
a person who may have been exposed to a communicable disease or
may otherwise be at risk of contracting or spreading the disease
or condition.
· Abuse
or Neglect: We
may disclose your medical information to a public health authority
that is authorized by law to receive reports of child abuse or
neglect. In addition; we may disclose your medical information
if we believe that you have been a victim of abuse, neglect or
domestic violence to the governmental entity or agency authorized
to receive such information. In this case, the disclosure will
be made consistent with the requirements of applicable federal
and state laws.
· Health
Oversight: We
may disclose medical information to a health oversight agency
for activities authorized by law, such as audits, investigations,
and inspections. Oversight agencies seeking this information include
government agencies that oversee the health care system, government
benefit programs, other government regulatory programs and civil
rights laws.
· Judicial
and Administrative Proceedings: We
may disclose your medical information in the course of a judicial
or administrative proceeding in response to an order of a court
or administrative tribunal. We may also disclose your medical
information in response to a subpoena, discovery request, or other
lawful process, but only if reasonable efforts have been made
to notify you of the request or to obtain a protective order limiting
the use of the information to the litigation or proceeding for
which it was requested.
· Law Enforcement:
We may also
disclose medical information, so long as applicable legal requirements
are met, for law enforcement purposes. These law enforcement purposes
include (1) legal processes and as otherwise required by law,
(2) limited information requests for identification and location
purposes, (3) pertaining to victims of a crime, (4) suspicion
that death has occurred as a result of criminal conduct; (5) in
the event that a crime occurs on the premises of Arise Prosthetics,
and (6) medical emergency (not on the Arise Prosthetics' premises)
and it is likely that a crime has occurred.
· Coroners,
Funeral Directors, and Organ Donation: We may disclose medical information
to a coroner or medical examiner for identification purposes,
determining cause of death or for the coroner or medical examiner
to perform other duties authorized by law. We may also disclose
protected health information to a funeral director, consistent
with applicable law, in order to permit the funeral director to
carry out their duties. We may disclose such information in reasonable
anticipation of death. Information may be used or disclosed to
organ procurement organizations or other entities engaged in the
procurement, banking, or transplantation of cadaveric organs,
eyes, or tissue for the purpose of facilitating organ, eye or
tissue donation and transplantation.
· Research: We may disclose your medical information to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
· Serious Threat to Health or Safety: Consistent
with applicable federal and Arizona state laws, we may disclose
your medical information, if we believe that the use or disclosure
is necessary to prevent or lessen a serious and imminent threat
to the health or safety of a person or the public. We may also
disclose medical information if it is necessary for law enforcement
authorities to identify or apprehend an individual because of
a statement by the individual admitting participation in a violent
crime that Arise Prosthetics reasonably believes may have caused
serious physical harm to the victim or where it appears from ail
the circumstances that the individual has escaped from a correctional
institution or from lawful custody.
· Military Activity and National Security: When
the appropriate conditions apply, we may use or disclose medical
information of individuals who are Armed Forces personnel (1)
for activities deemed necessary by appropriate military command
authorities; (2) for the purpose of a determination by the Department
of Veteran Affairs of your eligibility for benefits, or (3) to
foreign military authority if you are a member of that foreign
military services. We may also disclose your medical information
to authorized federal officials for conducting national security
and intelligence activities, including the provision of protective
services to the President or others legally authorized.
· Worker's Compensation: Your medical information may be disclosed by us as authorized to comply with workers' compensation laws and other similar legally established programs.
· Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
· Required Uses and Disclosures: Under the law;
we must make disclosures to you and when required by the Secretary
of the Department of Health and Human Services to investigate
or determine our compliance with the requirements of the law and
regulations.
· Appointment Reminders: We may use and disclose
medical information to contact you as a reminder that you have
an appointment for treatment or medical care at Arise Prosthetics.
· Treatment Alternatives: We may use and disclose
medical information to tell you about or recommend possible treatment
options or alternatives that may be of interest to you.
· Health-Related Benefits and Services. We may use
and disclose medical information to tell you about health-related
benefits or services that may be of interest to you.
B. Uses and Disclosures to Which You Have the Opportunity to Object.
We may use or disclose your medical information for any of the
purposes described in this section unless you affirmatively object
to or otherwise restrict a particular release. Please direct any
written objections or restrictions to Arise Prosthetics' Privacy
Officer at Arise Prosthetics LLC, 1830 West Colter, Suite 101,
Phoenix, AZ 85015.
· Patient Directory: Unless you object; we may include
certain limited information about you in the patient directory
while you are a patient. This information may include your name,
location in Arise Prosthetics, your general condition (e.g., fair,
stable, etc.) and your religious affiliation. The directory information,
except for your religious affiliation, may also be released to
people who ask for you by name. Your religious affiliation may
be given to a member of the clergy, such as a priest or rabbi;
even if they don't ask for you by name. This is so your family;
friends and clergy can visit you in Arise Prosthetics and generally
know how you are doing.
· 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, medical information
that directly relates to that person's involvement in your health
care. If you are unable to agree or object to such a disclosure,
we may disclose such information as necessary if we determine
that it is in your best interest based on our professional judgment.
We may use or disclose medical information to notify or assist
in notifying a family member, personal representative or any other
person that is responsible for your care of your location, general
condition or death. Finally, we may use or disclose medical information
to an authorized public or private entity to assist in disaster
relief efforts and to coordinate uses and disclosures to family
or other individuals involved in your health care.
· Fundraising Activities: We may use medical information
about you to contact you in an effort to raise money for Arise
Prosthetics and its operations. We may disclose medical information
to a foundation related to Arise Prosthetics so that the foundation
may contact you in raising money for Arise Prosthetics. We only
would release demographic information, such as your name, address
and phone number, and the dates you received treatment or services
at Arise Prosthetics. Any fundraising materials we send to you
must contain a description of how you may opt out of receiving
any further fundraising communications in the future.
C. Uses and Disclosures of Medical Information That Require
Your Authorization. Other uses and disclosures of your medical
information not covered by the preceding categories will be made
only with your written authorization. You may revoke this authorization
at any time, in writing, except to the extent that Arise Prosthetics
has already taken an action in reliance on your previous authorization.
We are required to abide by the terms of this notice which is
currently in effect. However, we reserve the right to change this
notice at any time. In addition, we reserve the right to make
the revised or changed notice effective for the medical information
we already have about you as well as any information we receive
in the future. We will post a copy of the current notice in Arise
Prosthetics. The notice will contain on the first page, in the
top right-hand corner, the effective date. In addition, each time
you register at or are admitted to Arise Prosthetics for treatment
or health care services as an inpatient or outpatient, we will
offer you a copy of the then current notice in effect.
If you believe your privacy rights have been violated; you may
file a complaint with us or with the Secretary of the Department
of Health and Human Services. To file a complaint with us, contact
Arise Prosthetics' Privacy Officer at Arise Prosthetics LLC, 1830
West Colter, Suite 101, Phoenix, AZ 85015. All complaints must
be submitted in writing. You will not be penalized for filing
a complaint.
Questions, comments and requests regarding the matters described
in this notice should be directed to the following:
Jackie Werner
Title: Privacy Officer
Address: 1830 West Colter, Suite 101, Phoenix, AZ 85015.
Telephone:(602) 864-5560
Facsimile: (602) 864-4958