Blue Dot Medical, 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.
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, a prescription or results of a respiratory assessment is available in your medical record to all health professionals who may provide treatment or be consulted by staff members.
Payment: Your health information may be used to seek payment from Medicare, Medicaid, your private health plan or other coverage that you may use to pay for services. For example, you health plan may request and receive information on dates of service, the services provided, and the condition treated.
Daily Operations: Your health information may be used as necessary to support the day-to-day activities and management of Blue Dot Medical, Inc. For example, your information may be used to evaluate and support quality improvement.
Law Enforcement: Your health information may be disclosed to government agencies to support audits, inspections, and/or 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 may be required to report certain communicable diseases.
Other Uses and Disclosures Require Your Authorization Disclosure of your health information or its use for any purpose 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 revoke that authorization in writing. However, a decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before receipt of your written revocation.
Additional Uses of Information Your health information may be used by our staff to send out appointment reminders.
Information about treatment: Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. We may also send information describing other health-related products and services that we believe may interest you.
Individual Rights You have certain rights under the federal privacy standards. They include:
§ The right to request restrictions on the use and disclosure of your protected health information. § The right to receive confidential communications concerning your medical condition and treatment. § The right to inspect and copy your protected health information. § 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 information is disclosed. § The right to receive a printed copy of this notice.
Blue Dot Medical, Inc. 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, as well as abide by the policies and practices outlined in this notice.
Right to Revise Privacy Practices We reserve the right to amend or modify our privacy policies and practices as permitted by law. We will try to avoid amendment or modification unless required by federal or state law, but if there is such and amendment or modification the revised policies will apply to all protected health information we maintain. You may request another copy of this notice at any time.
Request to Inspect Protected Health Information You may generally inspect or copy the protected health information that we maintain. We require that requests to inspect or make copies be submitted in writing. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.
Complaints If you wish to submit a comment or complaint about our privacy practices, or if you believe that your privacy rights have been violated, send your concerns to:
Blue Dot Medical, Inc. Attn: Privacy Officer 811 Foley St. Suite G Jackson, MS 39202-3433
You may also send a written complaint to:
Office of Civil Rights US Department of Health and Human Services 200 Independence Avenue, S. W. Washington, DC 20201
You will not be penalized or retaliated against if you file a complaint.
Effective Date This notice is in effect on or after April 14, 2003.
