Effective Date of this Notice: September 5, 2014
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.
For more information see: https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html
Your Rights
You have rights when it comes to your health information. These include the right to:
Receive an electronic or paper copy of your medical record.
To request a copy, contact UCP’s front desk at 602-943-5472 extension 2001 and request the Program Manager. We will provide a copy or summary of your health information within 30 days of the request. A reasonable fee may be charged.
Request corrections to your medical record
To request corrections to your health information, UCP’s front desk at 602-943-5472 extension 2001 and request the Program Manager. If your request is denied, you will receive an explanation in writing within 60 days.
Request confidential communications
If you would prefer that UCP only contact you in a specific way (for example, a home or office phone) or to send mail to a different address than is on file, contact UCP’s front desk at 602-943-5472 extension 2001 and request the Program Manager. All reasonable requests will be accommodated.
Request that UCP limit data used or shared
To request that UCP not use or share health information for treatment, payment, or our operations, UCP’s front desk at 602-943-5472 extension 2001 and request the Program Manager. Please note that UCP is not required to agree, and may deny the request if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you may request that information not be shared for the purpose of payment or our operations with your health insurer. Unless the law requires otherwise, this request will be accommodated.
Obtain a list of those with whom UCP has shared information
You may request a list (accounting) of times UCP has shared your health information for up to six years prior to the request date, who it was shared with, and why. All disclosures except those about treatment, payment, health care operations, and certain other disclosures (such as any you asked us to make) will be included. One accounting a year will be provided free of cost, however additional requests in a 12-month period will result in a reasonable, cost-based fee.
Receive a copy of this Privacy Notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. A paper copy will be provided promptly.
Designate someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
File a complaint
To file a complaint, individuals may contact the Quality Assurance and Compliance Manager at 602-999-9391. If further assistance is needed, individuals may contact:
UCP Privacy Officer
1802 West Parkside Lane
Phoenix, AZ 85027
P: 602-943-5472
OR
The Arizona Department of Health Services
1501 North 18thAvenue, Suite 450
Phoenix, AZ 85007
P: 602-364-3030
You also have the option to file a complaint with the US Department of Health and Human Service Office for Civil Rights by sending a letter to
https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html
UCP will not retaliate against any complaint filed against the agency.
Your Choices
For certain health information, you can decide what we share.
In these cases, you have both the right and choice to tell us whether or not to:
Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
We never share your information unless you give us written permission for the following:
Marketing purposes
Sale of your information, and
Most sharing of psychotherapy notes.
We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
We typically use or share your health information in the following ways:
For your treatment — We can use your health information and share it with other professionals who are treating you.
Running our organization — We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Billing for your services — We can use and share your health information to bill and receive payment from health plans or other entities.
Example: We provide information about you to your health insurance plan so it will pay for your services.
Other Disclosures:
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. However, we are required by law to meet many conditions before we can share your information for these purposes.
For more information see: https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/consumers/consumer_rights.pdf
Examples of other situations in which we may share your information are:
Helping with public health and safety issues — We can share health information about you for certain situations such as:
Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Research — We can use or share your information for health research.
To comply with the law — We will share information about you if state or federal laws require it, including with the Department of Health and Human Services.
In response to organ and tissue donation requests — We can share health information about you with organ procurement organizations.
For work with a medical examiner or funeral director — We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
To address workers’ compensation, law enforcement, and other government requests — We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
To respond to lawsuits and legal actions — We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach that may have compromised the privacy or security of your information occurs.
We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. You may change your mind at any time. Let us know in writing if you change your mind.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
