NOTICE OF PRIVACY INFORMATION 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.
PURPOSE OF THE NOTICE.
PMC is committed to preserving the privacy and confidentiality of your health information that is created and/or maintained at our clinic. This Notice describes the ways in which we may use or disclose your health information and also describes your rights and our obligations concerning such uses or disclosures.
The privacy practices described in this Notice will be followed by:
• Any health care professional authorized to enter information into your medical record created and/or
maintained at our clinic;
• All employees, students, residents, and other service providers who have access to your health
information at our clinic; and
• Any member of a volunteer group that is allowed to help you while receiving services at our clinic.
The individuals identified above will share your health information with each other for purposes of treatment, payment, and health care operations, as further described in the Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS.
• Treatment. We may use your health information to provide you with health care treatment and services.
We may disclose your health information to doctors, nurses, nursing assistants, technicians, medical and
nursing students, rehabilitation therapy specialists, or other personnel who are involved in your health care.
• Payment. We may use or disclose your health information so that we may bill and receive payment from
you, an insurance company, or another third party for the health care services you receive from us. We may
also disclose health information about you to your health plan in order to obtain prior approval for the
services we intend to provide to you, or to determine that your health plan will pay for treatment.
• Health Care Operations. We may use or disclose your health information in order to perform the
necessary administrative, educational, quality assurance, and business functions of our clinic.
USES AND DISCLOSURES OF HEALTH INFORMATION IN SPECIAL SITUATIONS.
• We may disclose your health information for purposes of contacting you to remind you of a health care
appointment.
• We may use or disclose your heath information for purposes of contacting you to inform you of treatment
alternatives or health-related products or services that may be of interest to you.
• We may disclose your health information to individuals, such as family members and friends, who are
involved in your care or who help pay for your care. We may make such disclosures when:
• We have your verbal agreement to do so;
• We make such disclosures and you do not object;
• We can infer from the circumstances that you would not object to such disclosures.
OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES OF HEALTH INFORMATION.
• As required by law, we may disclose your health information when required by federal, state, or local law
to do so without your consent.
• We may disclose your health information to public health authorities that are authorized to receive and
collect health information of purposes of preventing or controlling disease, injury, or disability; to report
births, deaths, suspected abuse or neglect, reactions to medications, or to facilitate product recalls without
your consent.
• We may disclose your health information to a health oversight agency that is authorized by law to conduct
health oversight activities, including audits, investigations, inspections, or licensure and certification
surveys without your consent.
• We may disclose your health information to worker’s compensation programs when your health condition
arises out of work-related illness or injury without your consent.
• We may disclose your health information in response to a request received from a law enforcement official
to report criminal activity or to respond to a subpoena, court order, warrant, summons, or similar process.
USES AND DISCLOSURES PURSUANT TO YOUR WRITTEN AUTHORIZATION.
Except for the above-mentioned conditions, we will not use or disclose your health information for any other purposes unless we have your specific written authorization. You have the right to revoke a written authorization at any time in writing.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION.
You have the following rights regarding your health information.
• You have the right to inspect and copy health information that may be used to make decisions about your
care.
• You have the right to request an amendment of your health information that is maintained by or for our
clinic and is used to make health care decisions about you.
• You have the right to request an accounting of the disclosures of your health information made by us.
• 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 have the right to request that we communicate with you about your health care in a certain way or at a
certain location. For example, you can ask that we only contact you at work or by mail.
• You have the right to receive a paper copy of this Notice.
QUESTIONS OR COMPLAINTS.
If you have any questions regarding this Notice, please contact:
Peter Leon Guerrero
Director
(671) 649-4501
If you believe that your privacy rights have been violated, you may mail your complaint to:
PMC Isla Health System
Attn: Peter Leon Guerrero
177 A Chalan Pasaheru, Ste. F
Tamuning, GU 96913
All complaints must be submitted in writing.
Effective Date 14 April, 2003
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