DONNA BELLA LLC
PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
As required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
OUR COMMITMENT: Donna Bella LLC is committed to maintaining the privacy of your protected health information ("PHI"), which includes information about your health condition and the care and treatment you receive from Donna Bella LLC. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI.
To summarize, this notice provide you with the following important information:
- How we may use and disclose your identifiable health information
- Your Privacy right in your identifiable health information
- Our obligations concerning the use and disclosure of your identifiable health information
The terms of this notice apply to all records containing your identifiable health information that are created or retained by our organization. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all your records our organization had created or maintained in the past, and for any of your records we may create or maintain in the future. Our organization will post a copy of our current notice in our offices, and in a prominent location. You may request a copy of our most current notice at any time.
Any question about this notice please contact:
Susan McMahon, Privacy Officer, C/O Donna Bella, 117 NW 2nd Street, Corvallis, Oregon 97330. 541-752-9649
WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS:
Donna Bella LLC may use and/or disclose your PHI provided that it first obtains a valid Consent signed by you. The Consent will allow Donna Bella LLC to use and/or disclose your PHI for the purposes of:
(a) Treatment –Donna Bella LLC may use your identifiable health information to treat you. For example, we may ask you to undergo special measurements and may use the results to help us make product selections for you. Many of the people who work for our organization may use or disclose your identifiable health information in order to treat you or assist others in your treatment. Additionally, we may disclose your identifiable health information to other who may assist in your case, such as your physician, therapist, spouse, children or parents.
(b) Payment – In order to get paid for services provided to you, Donna Bella LLC will provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements. We may contact your health insurer to certify that you are eligible for benefits (and the range of benefits) and we may provide your insurer with details regarding your product needs to determine if your insurer will cover, or pay for, your products. Also, we may use your identifiable health information to bill you directly for services and items.
(c) Health Care Operations – In order for Donna Bella LLC to operate in accordance with applicable law and insurance requirements and in order for Donna Bella LLC to continue to provide quality and efficient care, it may be necessary for Donna Bella LLC to compile, use and/or disclose your PHI. For example, Donna Bella LLC may use your PHI in order to evaluate the performance of Donna Bella LLC’s personnel in providing care to you.
(d) Business Associates - To a business associate if Donna Bella LLC obtains satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists Donna Bella LLC in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies or other payers.
(e) Appointment Reminders: Donna Bella LLC may, from time to time, contact you to remind you of appointments or deliveries.
(f) Release of Information to Family/Friends: Donna Bella LLC may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person's involvement with your care or the payment for your services.
(g) Treatment Alternatives – We may use and disclose medical information to contact you as a reminder that you have options or alternatives that my be of interest to you.
(h) Health-Related Benefits and Services – We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
AUTHORIZATION: Our organization will obtain your written authorization for uses and disclosures that are not identified by the notice or permitted by applicable law. Any authorization you provide regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. Please note: We are required to retain records of your care.
USE AND DISCLOSURE OF YOUR IDENTIFIABLE HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES:
The following describes unique scenarios in which we may use or disclose your identifiable health information:
(a) Disclosures Required by Law: Donna Bella LLC will use and disclose your identifiable health information when we are required to do so by federal, state or local law.
(b) De-identified Information – Information that does not identify you and, even without your name, cannot be used to identify you.
(c) Personal Representative – To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.
(d) Emergency Situations – (i) for the purpose of obtaining or rendering emergency treatment to you provided that Donna Bella LLC attempts to obtain your Consent as soon as possible; or (ii) to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation.
(e) Communication Barriers – If, due to substantial communication barriers or inability to communicate, Donna Bella LLC has been unable to obtain your Consent and Donna Bella LLC determines, in the exercise of its professional judgment, that your consent to receive treatment is clearly inferred from the circumstances.
(f) Public Health Activities - Information collected by a public health authority, as authorized by law, which generally include: prevention or control of disease, injury or disability, reporting reactions or problems with products, or to notify you on: product recalls, exposure to infectious diseases,
(g) Abuse, Neglect or Domestic Violence - To a government authority if Donna Bella LLC is required by law to make such disclosure. If Donna Bella LLC is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm.
(h) Health Oversight Activities - Such activities, which must be required by law, involve government agencies and may include, for example, criminal investigations, disciplinary actions, or general oversight activities relating to the community's health care system.
(i) Judicial and Administrative Proceeding - For example, Donna Bella LLC may be required to disclose your PHI in response to a court order or a lawfully issued subpoena.
(j) Law Enforcement Purposes - In certain instances, your PHI may have to be disclosed to a law enforcement official. For example, your PHI may be the subject of a grand jury subpoena. Or, Donna Bella LLC may disclose your PHI if Donna Bella LLC believes that your death was the result of criminal conduct.
(k) Coroner or Medical Examiner - Donna Bella LLC may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death.
(l) Research – Under certain circumstances, we may use and disclose your PHI for research purpose. For example, a research project may involve comparing the health and recovery of all patients who received one treatment to those who received another for the same condition. Most research projects, are subject to a special approval processes which require an evaluation of the proposed research and it’s use of PHI against the need for privacy.
(m) Avert a Threat to Health or Safety - Donna Bella LLC may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the threat.
(n) Workers' Compensation - If you are involved in a Workers' Compensation claim, Donna Bella LLC may be required to disclose your PHI to an individual or entity that is part of the Workers' Compensation system.
(o) National Security and Intelligence Activities – Donna Bella LLC may disclose your PHI in order to provide authorized governmental officials with necessary intelligence information for national security activities and purposes authorized by law.
(p) Military and Veterans – If you are a member of the armed forces, Donna Bella LLC may disclose your PHI as required by the military command authorities.
(q) Inmates – If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your PHI to the correctional institution or official under specific circumstances such as a.) for the institution to provide you with health care, b.) to protect your health and safety or the health and safety of others or c.) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION
You have the following rights regarding the identifiable health information we maintain about you:
(a) Confidential Communications. You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For example. You may wish that we contact you at home, rather than work. You must make your request in writing to Susan McMahon, Privacy Officer, C/O Donna Bella, 117 NW 2nd Street, Corvallis, Oregon 97330. Donna Bella LLC will accommodate all reasonable requests.
(b) Request Restrictions on certain use and/or disclosure of your PHI as provided by law. However, Donna Bella LLC is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to Susan McMahon, Privacy Officer, C/O Donna Bella, 117 NW 2nd Street, Corvallis, Oregon 97330. In your written request, you must inform us of what information you want to limit, whether you want to limit Donna Bella LLC's use or disclosure, or both, and to whom you want the limits to apply. If Donna Bella LLC agrees to your request, Donna Bella LLC will comply with your request unless the information is needed in order to provide you with emergency treatment.
(c) Revoke any Authorization and/or Consent, in writing, at any time. To request a revocation, you must submit a written request to Susan McMahon, Privacy Officer, C/O Donna Bella, 117 NW 2nd Street, Corvallis, Oregon 97330.
(d) Inspection and Copies: You have the right to inspect and copy your PHI. To inspect and copy your PHI, you must submit a written request to Susan McMahon, Privacy Officer, C/O Donna Bella, 117 NW 2nd Street, Corvallis, Oregon 97330. Donna Bella LLC can charge you a fee for the cost of copying, mailing or other supplies associated with your request. In certain situations that are defined by law, Donna Bella LLC may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written denial notice.
(e) Amendments: Amend your PHI as provided by law. To request an amendment, you must submit a written request to Susan McMahon, Privacy Officer, C/O Donna Bella, 117 NW 2nd Street, Corvallis, Oregon 97330. You must provide a reason that supports your request. Donna Bella LLC may deny your request if: a.) it is not in writing, b) if you do not provide a reason in support of your request, c) if the information to be amended was not created by Donna Bella LLC (unless the individual or entity that created the information is no longer available), d) if the information is not part of your PHI maintained by Donna Bella LLC, e) if the information is not part of the information you would be permitted to inspect and copy, or f) if the information is accurate and complete. If you disagree with Donna Bella LLC's denial, you will have the right to submit a written statement of disagreement.
(f) Accounting Disclosures: You have a right to receive an accounting of disclosures of your PHI as provided by law. To request an accounting, you must submit a written request to Susan McMahon, Privacy Officer, C/O Donna Bella, 117 NW 2nd Street, Corvallis, Oregon 97330. The request must state a time period which may not be longer than six (6) years and may not Include dates before April 14, 2003. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a twelve (12) month period will be free, but Donna Bella LLC may charge you for the cost of providing additional lists. Donna Bella LLC will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.
(g) Right to a Paper Copy. You have a right to receive a paper copy of our Privacy Notice. To obtain a copy of this notice contact Susan McMahon, Privacy Officer, C/O Donna Bella, 117 NW 2nd Street, Corvallis, Oregon 97330, 541-752-9649.
(h) File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with Donna Bella LLC or to the Secretary of Health and Human Services. To file a complaint with Donna Bella LLC, you must contact Donna Bella Susan McMahon, Privacy Officer, C/O Donna Bella, 117 NW 2nd Street, Corvallis, Oregon 97330. All complaints must be in writing. There will be no retaliation for filing a complaint.