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Privacy
PRIVACY POLICY STATEMENT SUMMARY
THIS IS AN ABRIDGED VERSION FOR INFORMATIONAL PURPOSES
ONLY.
ALL PATIENTS RECEIVE THE FULL VERSION.
Purpose: The following privacy policy is adopted to ensure
that Middlebury Surgical, LLC complies fully with all federal and
state privacy protection laws and regulations. Protection of patient
privacy is of paramount importance to this organization.
Assigning Privacy and Security Responsibilities
It is the policy of Middlebury Surgical, LLC that specific individuals
within our workforce are assigned the responsibility of implementing
and maintaining HIPAA Privacy Policies. Furthermore, it is the policy
of Middlebury Surgical, LLC that these individuals will be provided
sufficient resources and authority to fulfill their responsibilities.
At a minimum it is the policy of Middlebury Surgical, LLC that there
will be one individual or job description designated as the Privacy
Official.
Uses and Disclosures of Protected Health Information
It is the policy of Middlebury Surgical, LLC that protected
health information may not be used or disclosed except when at least
one of the following conditions is true:
1. The individual who is the subject of the information (i.e. the
"subject individual") has authorized the use or disclosure.
2. The use or disclosure is for an individual's treatment, payment
or health care operations.
3. The individual who is the subject of the information does not
object to the disclosure and the disclosure is to friends or family
members involved in the health care of the individual.
4. The disclosure is to the individual who is the subject of the
information or to HHS for compliance-related purposes.
5. The use or disclosure is otherwise permitted or required by HIPAA.
Deceased Individuals
It is the policy of Middlebury Surgical, LLC that privacy protections
extend to information concerning deceased individuals.
Notice of Privacy Practices
It is the policy of Middlebury Surgical, LLC that a notice of privacy
practices must be provided to all patients at the earliest practicable
time and posted in our office, that any revised notice be available
to patients upon request and that all uses and disclosures of protected
health information be done in accord with this organization's notice
of privacy practices.
Restriction Requests
It is the policy of Middlebury Surgical, LLC that consideration
must be given to all requests for restrictions on uses and disclosures
of protected health information as stated in this organization's
notice of privacy practices. It is furthermore the policy of this
organization that if a particular restriction is agreed to, then
this organization is bound by that restriction.
Minimum Necessary Disclosure of Protected Health Information
It is the policy of Middlebury Surgical, LLC that (except for
disclosures to a health care provider made for treatment purposes,
disclosures to the patient, disclosures pursuant to an authorization,
or disclosures to the Secretary of DHHS for HIPAA compliance purposes)
all uses and disclosures of protected health information must be
limited to the minimum amount of information needed to accomplish
the purpose of the use or disclosure. It is also the policy of this
organization that all requests for protected health information
(except requests made for treatment purposes) must be limited to
the minimum amount of information needed to accomplish the purpose
of the request.
Access to Protected Health Information by Workforce Members
It is the policy of Middlebury Surgical, LLC that access to
protected health information must be granted to each employee or
contractor based on the assigned job functions of the employee or
contractor only as necessary to accomplish the assigned job function.
Access to Protected Health Information by the Subject Individual
It is the policy of Middlebury Surgical, LLC that, where required
by state law or HIPAA, access to protected health information must
be granted to the person who is the subject of such information
within the timeframes required by state law or the HIPAA Privacy
Rule. It is the policy of Middlebury Surgical, LLC to inform the
person requesting access of the location of protected health information
if we do not physically possess such PHI but have knowledge of its
location.
Amendment of Incomplete or Incorrect Protected Health Information
It is the policy of Middlebury Surgical, LLC that all requests
for amendment of protected health information maintained by this
organization will be considered in a timely fashion. If such requests
demonstrate that the information is actually incorrect or incomplete,
this organization will allow amending language to be added to the
appropriate document and this addition will be done in a timely
fashion. It is not the policy of this organization to change, remove
or strike through any original document. It is also the policy of
this organization that notice of such corrections will be given
to any person or organization with which the incorrect information
has been shared who have relied or may rely on such information
to the detriment of the patient.
Access by Personal Representatives
It is the policy of Middlebury Surgical, LLC that access to protected
health information must be granted to personal representatives of
subject individuals as specified by subject individuals, unless
there is reason to believe that the individual has been or may be
subjected to domestic violence, abuse or neglect by the personal
representative, or that treating the person as the individual's
personal representative may endanger the individual, and we determine
that it is not in the individual's best interests to treat the person
as the individual's personal representative.
Confidential Communications Channels
It is the policy of Middlebury Surgical, LLC that confidential communications
channels be used, as requested by subject individuals, to the extent
possible.
Disclosure Accounting
It is the policy of Middlebury Surgical, LLC that an accounting
of all disclosures of protected health information to which an individual
has a right to an receive an accounting be given to subject individuals
whenever such an accounting is requested.
Marketing Activities
It is the policy of this Middlebury Surgical, LLC that any uses
or disclosures of protected health information for marketing activities
will be done only after a valid authorization is in effect.
Complaints
It is the policy of Middlebury Surgical, LLC that all complaints
relating to the privacy of health information be investigated and
resolved in a timely fashion. Furthermore, it is the policy of this
Middlebury Surgical, LLC that all complaints will be addressed to
<name or job title of person authorized to handle complaints
(ie. Privacy Official)> who will be duly authorized to investigate
complaints and implement resolutions if the complaint stems from
a valid area of non compliance with the HIPAA Privacy Rule.
Prohibited Activities
It is the policy of Middlebury Surgical, LLC that no employee or
contractor may engage in any intimidating or retaliatory acts against
persons who file complaints or otherwise exercise their rights under
HIPAA regulations. It is also the policy of this organization that
no employee or contractor may condition treatment, payment, enrollment
or eligibility for benefits on the provision of an authorization
to disclose protected health information, except in specifically
permitted circumstances.
Responsibility
It is the policy of Middlebury Surgical, LLC that the responsibility
for designing and implementing procedures to implement this policy
lies with the chief privacy officer (i.e. "CPO").
Verification of Identity
It is the policy of Middlebury Surgical, LLC that the identity and
authority of all persons who request access to protected health
information be verified before such access is granted as required
under the HIPAA Privacy Rule.
Mitigation
It is the policy of Middlebury Surgical, LLC that the effects of
any unauthorized use or disclosure of protected health information
be mitigated to the extent possible.
Safeguards
It is the policy of this Middlebury Surgical, LLC that appropriate
administrative, technical and physical safeguards will be in place
to reasonably safeguard protected health information from any intentional
or unintentional use or disclosure that is in violation of the HIPAA
Privacy Rule. These safeguards apply to information maintained in
any form, including oral information, as applicable.
Business Associates
It is the policy of Middlebury Surgical, LLC that business associates
must be contractually bound to protect health information to the
same degree as set forth in this policy. It is also the policy of
this organization that business associates who violate their agreement
will be dealt with first by an attempt to correct the problem, and
if that fails by termination of the agreement and discontinuation
of services by the business associate and/or notification to the
Secretary of DHHS.
Training and Awareness
It is the policy of this Middlebury Surgical, LLC that all members
of our workforce have been trained by the compliance date on the
policies and procedures governing protected health information and
how Middlebury Surgical, LLC complies with the HIPAA Privacy and
Rule. It is also the policy of Middlebury Surgical, LLC that new
members of our workforce receive training on these matters within
a reasonable (you may elect to enter the exact time frame) time
after they have joined the workforce. It is the policy of Middlebury
Surgical, LLC to provide training should any policy or procedure
related to the HIPAA Privacy Rule materially change. This training
will be provided within a reasonable time (you may elect to enter
the exact time frame) after the policy or procedure materially changes.
Furthermore, it is the policy of Middlebury Surgical, LLC that training
will be documented indicating participants, date and subject matter.
Retention of Records
It is the policy of this Middlebury Surgical, LLC that the HIPAA
Privacy Rule records retention requirement of six years will be
strictly adhered to. All records designated by HIPAA in this retention
requirement will be maintained in a manner that allows for access
within a reasonable period of time. This records retention time
requirement may be extended at this organization's discretion to
meet with other governmental regulations or those requirements imposed
by our professional liability carrier.
Cooperation with Privacy Oversight Authorities
It is the policy of Middlebury Surgical, LLC that oversight agencies
such as the Office for Civil Rights of the Department of Health
and Human Services be given full support and cooperation in their
efforts to ensure the protection of health information within this
organization. It is also the policy of this organization to cooperate
with privacy compliance reviews and investigations in accordance
with the requirements of HIPAA and other applicable law.
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