Notice of Privacy
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.
I. Who Presents this Notice
This Notice describes the privacy practices of Capitol Imaging Services (CIS) (“Organization”), including members of its workforce, employed or contracted physicians and allied health professionals who provide services at Organization’s practice locations or otherwise on Organization’s behalf. The Organization and the individual health care providers together are sometimes called “the Organization and Health Professionals” in this Notice. While the Organization and Health Professionals engage in many joint activities and provide services in a clinically integrated care setting, the Organization and Health Professionals each are separate legal entities. This Notice applies to services furnished to you at:
Advanced Imaging of Lafayette, 935 Camellia Boulevard #101, Lafayette, LA 70508
Ascension Open MRI, 2622 South Ruby Avenue, Gonzales, LA 70737
Baton Rouge Imaging, 8044 Summa Avenue, Baton Rouge, LA 70809
Bluebonnet Imaging, 4570 Bluebonnet Boulevard #A, Baton Rouge, LA 70809
Central Imaging, 11424 Sullivan Road, Building B #C, Baton Rouge, LA 70818
Central MS Diagnostics, 1 Layfair Drive, Building B #315, Flowood MS 39232
Diagnostic Imaging Services, 1200 Pinnacle Parkway #5, Covington, LA 70433
Diagnostic Imaging Services, 71154 Highway 21, Covington, LA 70433
Diagnostic Imaging Services, 925 Avenue C, Marrero, LA 70072
Diagnostic Imaging Services, 3434 Houma Boulevard #100, Metairie, LA 70006
Diagnostic Imaging Services, 4241 Veterans Memorial Boulevard, Suite 100, Metairie, LA 70006
Diagnostic Imaging Services, 1310 Gause Boulevard, Slidell, LA 70458
Doctors Imaging, 4204 Teuton Street, Metairie, LA 70006
Heritage Diagnostic Center, 1705 Main Avenue SW #C, Cullman, AL 35055
Homosassa Open MRI, 8464 West Aquaduct Street, Homosassa, FL 34448
Louisiana PET/CT Imaging Institute of Lake Charles, 831 Lakeshore Drive, Lake Charles, LA 70601
M.R. Imaging Systems, 211 North 3rd Street, Alexandria, LA 71301
Northeast Imaging, 1703 Lamy Lane, Monroe, LA 71201
Northwest Imaging, 1460 East Bert Kouns Industrial Loop #708, Shreveport, LA 71105
Open MRI of Hammond, 42078 Veterans Avenue #F, Hammond, LA 70403
OpenSided MRI of New Orleans, 1 Galleria Boulevard #715, Metairie, LA 70001
River Bend Imaging, 490 Belle Terre Boulevard, Laplace, LA 70068
Southern Imaging Specialists, 465 Saint Lukes Drive, Montgomery, AL 36117
Texarkana PET/CT Imaging Institute, 1j929 Moores Lane, Texarkana, TX 75503
Vestavia Hills Imaging Center, 2017 Canyon Road #25, Vestavia Hills, AL 35216
The Organization and health Professionals each are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When the Organization and Health Professionals use or disclose your Protected Health Information, the Organization and Health Professionals are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
II. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which are described in Section IV below, your written authorization must be obtained in order to use and/or disclose your PHI. However, the Organization and Health Professionals do not need any type of authorization from you for the following uses and disclosures:
A. Uses and Disclosures for Treatment, Payment and Health Care Operations. Your PHI, but not your “Highly Confidential Information” (defined in Section IV.C below), may be used in order to treat you, obtain payment for services provided to you and conduct our “health care operations” as detailed below:
Treatment. Your PHI may be used and disclosed to provide treatment and other services to you–for example, diagnose and treat your injury or illness. In addition, you may be contacted to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Your PHI also may be disclosed to other providers involved in your treatment.
Payment. Your PHI may be used and disclosed to obtain payment for services provided to you–for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”) to verify that Your Payor will pay for health care.
Health Care Operations. Your PHI may be used and disclosed for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care delivered to you (except for billing audits which require your Authorization under Louisiana law). For example, PHI may be used to evaluate the quality and competence of physicians, nurses or other health care workers. PHI may be disclosed to the Privacy Officer in order to resolve any complaints you may have.
Your PHI also may be disclosed to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance (except for billing audits which require your Authorization under Louisiana law). In addition, PHI may be shared with business associates who perform treatment, payment and health care operations services on our behalf of the Organization and Health Professionals.
B. Disclosure to Relatives, Close Friends and Other Caregivers. Your PHI may be disclosed to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if (1) your agreement is obtained; (2) you do not object to the disclosure after being provided the opportunity to object; or (3) it can be reasonably inferred that you do not object to the disclosure.
If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, the Organization and/or Health Professionals may exercise professional judgment to determine whether a disclosure is in your best interests. If information is disclosed to a family member, other relative or a close personal friend, the Organization and /or Health Professionals would disclose only information believed to be directly relevant to the person’s involvement with your health care or payment related to your health care. Your PHI also may be disclosed in order to notify (or assist in notifying) such persons of your location or general condition.
C. Public Health Activities. Your PHI may be disclosed for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability or otherwise reporting births, abortions, severe head injuries, cancers, the misadministration of radiopharmaceuticals, the presence of lead in your blood stream or that you are engaged in a lead hazard reduction activity, and for certain other public health reporting purposes as required under Louisiana law; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
D. Victims of Abuse, Neglect or Domestic Violence. Your PHI may be disclosed to a governmental authority, including the Louisiana Department of Health and Hospitals, the Medicaid Fraud Control Unit or a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence if there is a reasonable belief that you are a victim of abuse, neglect or domestic violence.
E. Health Oversight Activities. Your PHI may be disclosed to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
F. Judicial and Administrative Proceedings. Your PHI may be disclosed in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
G. Law Enforcement Officials. Your PHI may be disclosed to a coroner or medical examiner as authorized by law.
H. Decedents. Your PHI may be disclosed to a coroner or medical examiner as authorized by law.
I. Organ and Tissue Procurement. Your PHI may be disclosed to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
J. Health or Safety. Your PHI may be disclosed to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety as permitted or required by Louisiana law.
K. Specialized Government Functions. Your PHI may be disclosed to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
L. Workers’ Compensation. Your PHI may be disclosed as authorized by and to the extent necessary to comply with Louisiana law relating to workers’ compensation or other similar programs.
M. As Required by Law. Your PHI may be disclosed when required to do so by any other law not already referred to in the preceding categories.
III. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III, your PHI may be used or disclosed only when you provide us your written authorization on our authorization form (“Your Authorization”). For instance, you will need to execute an authorization form before your PHI can be sent to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
B. Marketing. Your written authorization (“Your Marketing Authorization”) also must be obtained prior to using your PHI to send you any marketing materials. However, marketing materials can be provided to you in a face-to-face encounter without obtaining Your Marketing Authorization. The Organization and/or Health Professionals are also permitted to give you a promotional gift of nominal value, if they so choose, without obtaining Your Marketing Authorization. In addition, the Organization and/or Health Professionals may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.
C. Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about HIV/AIDS testing, diagnosis or treatment, (4) is about genetic information (and the genetic testing is for purposes other than investigating a death or crime, determining paternity, determining the identify of a deceased person, for anonymous research where the patient’s identity will not be released, pursuant to newborn screening requirements or as otherwise authorized by federal law for identification purposes); (5) is about child abuse and neglect; (6) is about sexual assault (provided that if the patient is age sixteen (16) or younger, we are required by Louisiana law to immediately notify the appropriate law enforcement official); (7) is about the making or acceptance of an anatomical gift; or (8) if the patient is a child, is about such child including such child’s immunization records. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization is required.
For disclosures of genetic information, such authorization must include at least the following information: (a) be in writing, signed and dated by the patient; (b) identify the person permitted to make the disclosure; (c) describe the specific genetic information to be disclosed; (d) describe the purpose of the disclosure; (e) state an expiration date, which can never be more than sixty (60) days after the date of authorization; (f) a statement that the patient may revoke the authorization any time before the disclosure is actually made or the patient is made aware of the details of the genetic information; and (g) a statement that the authorization shall be invalid if used for any purpose other than that specified in the authorization.
IV. Your Rights Regarding Your Protected Health Information
A. For Further Information, Complaints. If you desire further information about your privacy rights, are concerned that your privacy rights have been violated or disagree with a decision made about access to your PHI, you may contact the Privacy Officer. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Officer will provide you with the correct address for the Director. The Organization and Health Professionals will not retaliate against you if you file a complaint with the Privacy Officer or the Director.
B. Right to Request Additional Restrictions. You may request restrictions on the use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While all requests for additional restrictions will be carefully considered, the Organization and Health Professionals are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from the Privacy Officer and submit the completed form to the Privacy Officer. A written response will be sent to you.
C. Right to Receive Confidential Communications. You may request, and the Organization and Health Professionals will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
D. Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that the Organization and Health Professionals have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Officer identified below. A form of written revocation is available upon request from the Privacy Officer.
E. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by the Organization or Health Professionals in order to inspect and request copies of the records. Under limited circumstances, you may be denied access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Officer and submit the completed form to the Privacy Officer. If you request copies of paper records, you will be charged in accordance with federal and state law. To the extent the request for records includes portions of records which are not in paper for m (e.g., x-ray films), you will be charged the reasonable cost of the copies. You will also be charged for the postage costs, if you request that the copies be mailed to you.
F. Right to Amend Your Records. You have the right to request that Protected Health Information in your medical record file or billing records be amended. If you desire to amend your records, please obtain an amendment request form from the Privacy Officer and submit the completed form to the Privacy Officer. Your request will be accommodated unless the Organization and/or Health Professionals believe that the information that would be amended is accurate and complete or other special circumstances apply.
G. Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003 If you request an accounting more than once during a twelve (12) month period, you will be charged $1.00 for each page for the first 25 pages, $0.50 per page for each page between 25-500 pages and $0.25 per page for pages 501 and higher of the accounting statement.
H. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
V. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective as of December 8, 2003.
B. Right to Change Terms of this Notice. The terms of this Notice may be changed at any time. If this Notice is changed, the new notice terms may be made effective for all PHI that the Organization and Health Professionals maintain, including any information created or received prior to issuing the new notice. If this Notice is changed, the new notice will be posted in waiting areas of the Organization’s practice locations and on the Organization’s Internet site at capitolimagingservices.com. You also may obtain any new notice by contacting the Privacy Officer.
VI. Privacy Officer
You may contact the Privacy Officer at:
Capitol Imaging Services
4241 Veterans Memorial Boulevard #200
Metairie, LA 70006