WEB SITE RELATED
NOTICE OF PRIVACY PRACTICES
If you have questions about this notice, please ask a research staff member or contact the Chief Operating Officer at our Administrative Office at 2141 E. Broadway Road, Suite 110, Tempe, AZ 85282 (480) 820-5656.
WHO WILL FOLLOW THIS NOTICE
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your health, health status, and the health care and services you receive from the research site.
We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We will request your written, signed Consent in order to use and disclose your health information for the following purposes.
For Treatment We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors or other medical professionals who are involved in taking care of you during a research trial.
For example, information obtained by a research study coordinator will be recorded in your record and used to ensure your safe participation in the research trial. We may provide your physician or a subsequent healthcare provider with copies of various reports so they can help determine the most appropriate care for you.
Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your study participation, such as contacting the trial sponsor regarding specific issues or needs you may have. Family members and other health care providers may be part of your medical care outside this office and may require information about you that we have.
For Clinical Trial Outcome Data We may use and disclose health information about you as part of our obligation to the study sponsor to provide the appropriate medical information necessary for the completion of a successful clinical trial.
For Clinical Trial Operations We may use and disclose health information about you in order to run the office and make sure that you and our other subjects receive quality care during the clinical trial. For example, we may use your health information to evaluate the performance of our staff in conducting the study. We may also use health information about all or many of our subjects to help us decide how we can become more efficient in conducting a clinical trial.
Appointment Reminders We may contact you as a reminder that you have an appointment for treatment or medical care from our office.
Treatment Alternatives We may tell you about alternative clinical trials that may be of interest to you.
Health-Related Products and Services We may tell you about health-related products or services that may be of interest to you.
Please notify us if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about clinical trial alternatives or health-related products and services. If you advise us in writing at the address listed at the top of this notice that you do not wish to receive such communications, we will not use or disclose your information for these purposes.
You may revoke your Consent at any time by giving us written notice. Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures that occurred before that time.
If you do revoke your Consent, we will not be permitted to use or disclose information for purposes of treatment, clinical trial outcome data, or clinical trial operations, and you will be discontinued from participation in the clinical trial.
To Avert a Serious Threat to Health or Safety We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety, or the health and safety of the public, or another person.
Required By Law We will disclose health information about you when required to do so by federal, state, or local law.
Organ and Tissue Donation If you are an organ donor, we may release information to organizations that handle organ procurement of organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate such donation and transplantation.
Military, Veterans, National Security and Intelligence If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
Public Health Risks We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
Health Oversight Activities We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.
Law Enforcement We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
Information Not Personally Identifiable We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Family and Friends We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room during treatment or while treatment is discussed.
In situations where you are not capable of giving consent because you are not present or due to your incapacity or medical emergency, we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. We may use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, supplies.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization (different than the Authorization and Consent mentioned above) from you. In order to disclose these types of records for purposes of treatment, payment or health care operations, we will have to have both your signed Consent and a special written Authorization that complies with the law governing HIV or substance abuse records.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
Right to Inspect and Copy You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care. You must submit a written request to Tara Banjo in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Right to Amend If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office.
To request an amendment, complete and submit a Medical Record Amendment/Correction Form to David Bruggeman. 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:
Right to Accounting Disclosures You have the right to request an “accounting of disclosures”. This is a list of the disclosures we made of medical information about you for purposes other than treatment, payment and health care operations. To obtain this list, you must submit your request in writing to David Bruggeman. It 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, etc.). We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions You have the right to request a restriction or limitation on the health 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 health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a specific test or piece of equipment you received.
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. To request restrictions, you may complete and submit the Request For Restriction On Use/Disclosure Of Medical Information And/Or Confidential Communication to David Bruggeman.
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.
To request confidential communications, you may complete and submit the Request For Restriction On Use/Disclosure Of Medical Information And/Or Confidential Communication to David Bruggeman. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of this Notice You have the right to 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 it electronically, you are still entitled to a paper copy. To obtain such a copy, contact David Bruggeman.
CHANGES TO THIS NOTICE