Notice of Privacy Practices
Polymap Wireless is committed to protecting your medical information. Polymap Wireless is required by law to maintain the privacy of your medical information, provide this notice to you, and abide by the terms of this notice. We reserve the right to change our privacy practices and the terms of this notice at any time. 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. (Effective date: 12/1/2003).
Confidentiality Practices and Uses
Protected Health Information (PHI) -- PHI is information we obtain and create in providing our services to you. Such information may include documentation of your symptoms, examination and test results, diagnosis and treatment. It also includes billing documents for those services.
USES AND DISCLOSURES NOT REQUIRING YOUR PERMISSION
Polymap Wireless operates as an agent of your medical provider. Your medical care provider may access, use and/or share this medical information for the purposes of the following:
- Treatment -- To appropriately determine approvals or denials of your medical treatment. For example, your PHI will be shared among members of your treatment team.
- Payment -- we may use or disclose your PHI in order to bill and collect payment for your health care services. For example, your health care provider may send claims for payment to Medicare for medical services provided to you, if appropriate
- Health Care Operations -- Your provider may use or disclose your PHI, as needed, in order to improve the quality of your care. For example, members of the treatment team may share PHI to assess the care and outcomes in your case.
- When Required by Law -- Your provider may disclose PHI when a law requires that we report information about suspected abuse, neglect or domestic violence, for a crime committed on the premises, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.
- For Public Health Activities -- Your provider may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics or the results of public health surveillance, investigations or interventions.
- For Health Oversight Activities -- Your provider may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the behavioral health care system, government programs and compliance with civil rights laws.
- Relating to Decedents -- Your provider may disclose PHI relating to a death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.
- For Research Purposes -- Your provider may use or disclose your medical information for research projects, such as studying the effectiveness of a treatment you received. These research projects must go through a special process that protects the confidentiality of your medical information. We will obtain your written authorization if the researcher will use or disclose your medical information.
- To Avert Threat to Health or Safety -- In order to avoid a serious threat to health or safety, your provider may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.
- For Specific Government Functions -- Your provider may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government benefit programs relating to eligibility and enrollment, and for national security reasons, such as protection of the President.
USES AND DISCLOSURES REQUIRING AUTHORIZATION
We are required to have your written authorization for the following. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we have already undertaken an action in based upon your authorization. Substance Abuse Health Information -- All PHI regarding substance abuse is to be kept strictly confidential and released only in conformance with the requirements of federal law (42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3) and regulation (42 C.F.R. part 2). Disclosure of any medical information referencing alcohol or substance abuse may be made only with your written authorization. A general authorization for the release of or other information is not sufficient for this purpose. HIV Information -- All PHI regarding HIV is kept strictly confidential and released only in conformance with the requirements of state law. Disclosure of any medical information referencing HIV status may only be made with your written authorization. A general authorization for the release of medical or other information is not sufficient for this purpose.
USES AND DISCLOSURES REQUIRING YOU TO HAVE AN OPPORTUNITY TO OBJECT
In the following situations, your provider may disclose a limited amount of your PHI if we inform you about the disclosure in advance and you do not object, as long as the disclosure is not otherwise prohibited by law:
- To Families, Friends or Others Involved in Your Care -- Your provider may share with these people information directly related to their involvement in your care, or payment for your care. Your provider may also share PHI with these people or notify them about your location and general condition.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
- Right to Request Restrictions -- You have the right to request that we restrict uses or disclosures of your health information to carry out treatment, payment, health care operations, or communications with family, friends, or other individuals. We are not required to agree to a restriction. If disclosure is required by law, we cannot agree to your request to restrict.
- Right to Request Confidential Communications -- You have the right to ask us to communicate with you in a way that you feel is more confidential. For example, you can ask us not to call your home, but to communicate only by mail. This request must be in writing.
- Right to Inspect and Copy -- You have the right to review your record (while a patient in the Hospital, only in the presence of the Attending Physician or their designee) and to get a copy of your record (the law requires us to keep the original record). This could include your health care Designated Record Set, your billing record, and other records we use to make decisions about your care. To request your medical information, write to the Health Information Management Department. If you request a copy of your information, we will tell you in advance what this copying will cost. We may deny your request to inspect and copy in certain circumstances as defined by law and Hospital policy.
- Right to Amend -- If you examine your medical information and believe that some of the information is incorrect, you may ask us to amend your record. The request must be in writing. Your request must include the reason or reasons that support your request. We may deny your request for an amendment if we determine that the record that is the subject of the request was not created by us, is not available for inspection as specified by law, or is accurate and complete.
- Right to Receive an Accounting of Disclosures -- You have the right to receive an accounting of disclosures of your health information created by us. This does not include disclosures made to carry out treatment, payment and health care operations; disclosures made to you; communications with family and friends; for national security or intelligence purposes; to correctional institutions or law enforcement officials; or disclosures made prior to the HIPAA compliance date of April 14, 2003. We will respond to your written request for such a list within 60 days of receiving it. Your first request for accounting in any 12-month period shall be provided without charge. A fee shall be imposed for each subsequent request.
- You have the right to receive this notice -- You have the right to receive a paper copy of this Notice.
HOW TO FILE A COMPLAINT IF YOU BELIEVE YOUR RIGHTS HAVE BEEN VIOLATED
If you have questions about this Notice or any complaints about our privacy practices, please contact Polymap Wireless at 520-747-1811.
You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services at:
U.S. Department of Health and Human Services
Office of Civil Rights
50 United Nations Plaza -- Room 322
San Francisco, California 94102
Attn: Regional Manager
Or call for a complaint form at 1-800-368-1019
We will take no retaliatory action against you if you make such complaints.
Effective Date: This notice is effective on December 1, 2003.
If you have any questions about this privacy statement, the practices of this site, or your dealings with this Web site, you can contact:
Polymap Wireless LLC
310 S. Williams Blvd., Suite 350
Tucson, AZ 85711
fax: (520) 747-9408