Notice of Privacy Policy

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR HEALTH MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE READ IT CAREFULLY.

Jody Meza, Practice Administrator
Alpine Medical Group, LLC
Internal Medicine
1060 East 100 South, L10
Salt Lake City, UT 84102
Phone: 801.328.1260

Purpose of Notice:
This Notice of Privacy Practices describes established privacy practices followed by our staff in relation to your protected health information (PHI). This notice will explain under how and when we may use and disclose our PHI, but may not include every possible circumstance. Again, please direct any questions to the compliance officer noted above.

Your Protected Health Information (PHI):
This notice addresses information and records we maintain about your health, health status, and the health care services provided for you at our office. This information may include information collected and/or recorded in our office, as well as information we may have received from previous health care providers. The information may be in written, electronic, or spoken form. It may also include information about your health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity, and similar categories of health-related information.

We are required by law to give you this notice. It will explain how and when we may use and disclose your PHI, and your rights about the use of that information.

How We May Disclose Your PHI Without Your Consent:

• For Treatment: Alpine Medical may use or disclose information with health care providers who specifically provide health care services to you. This may include, but is not limited to, doctors, nurses, technicians, office staff, or other personnel who are involved in your care. Personnel in our office may share information to coordinate your care, such as phoning in your prescriptions to your preferred pharmacy, scheduling lab work and tests, and ordering x-rays. Family members and other health care providers outside of our office may also require information about you in order to improve your treatment.
• For Payment: Alpine Medical may use or disclose your PHI in order to bill for services provided and receive payment from an insurance company or other third party. Insurance companies may require information about a specific visit or procedure, or require information in order to pre-approve future services. Alpine Medical may use or disclose this information for these purposes.
• For Health Care Operations: Alpine Medical may use or disclose your PHI in order to operate and/or improve the office. For example, Alpine Medical may use your PHI to review the quality of the services you have received.
• Utah Health Information Exchange (UHIN): Alpine Medical participates with Utah Health Information Network.

UHIN is a computer-based, secure method of exchanging or disclosing patient health information with other medically-related organizations, for the purposes of health care treatment, payment, and operations.

Benefits of UHIN:

• Helps coordinate your care among all of your health care providers.
• Reduces duplicative tests and associated costs.
• Improves the quality and safety of your treatment by providing more complete information to your health care providers.
• Increases the privacy of your health care information through encryption, authentication, access controls, and other security mechanisms.

Certain information, in certain cases, can be specially protected by law and require additional authorization. Alpine Medical may ask you to provide information, or “opt-in” to disclose the following:

• Mental health treatment information
• Substance abuse treatment information

(NOTE: Mental health and substance abuse treatment information is only specially protected information for certain federally funded substance abuse and mental health providers with Alpine. These providers will be designated and will be the only ones that need to obtain additional authorization.)

• Business Associates: Alpine Medical may contract with Business Associates who may perform certain functions and activities on our behalf. Our Business Associates are required to safeguard your PHI.
• Appointment Reminders: Alpine Medical may contact you directly or leave messages as a reminder of your appointment services.
• Insurance Verification: Alpine Medical may contact your insurance company via telephone or their website to verify your insurance enrollment status.
• Treatment Alternatives: Alpine Medical may contact your about possible treatment alternatives.
• Health-Related Products and Services: Alpine Medical may contact you about health-related products and services that may be of interest to you.

Other Situations in Which Alpine Medical may Release Your PHI Without Your Consent:

• As Required by Law: Alpine Medical will use and disclose your PHI when required by federal, state, or local law or by a court order. Alpine Medical may disclose your PHI in response to a subpoena, warrant, summons, or similar process subject to all legal requirements.
• For Abuse Reports or to Avert a Serious Threat to Health or Safety: Alpine Medical may use and disclose your PHI in order to meet its legal mandatory reporting requirements, or to prevent a serious threat to your health and safety or the health and safety of the public or another person.
• Research: Alpine Medical may use and disclose PHI for research projects, if you have consented to participate in the study. If you have voluntarily consented to participation in a research study, researchers will be subject to the same PHI restrictions as Alpine Medical.
• Organ and Tissue Donation: If you are an organ donor, Alpine Medical may use or disclose your PHI to organizations that handle organ procurement to facilitate organ donation.
• Military, Veterans, National Security, and Intelligence: If you are, or were, a member of the armed forces, or part of the national security or intelligence communities, Alpine Medical may use or disclose your PHI to military command or other government authorities as required. Alpine Medical may also release PHI about foreign military personnel to the appropriate foreign military authority.
• Workers Compensation: Alpine Medical may use or disclose your PHI for workers compensation or similar programs. Such programs provide benefits for work-related injuries or illness.
• Public Health Risks: Alpine Medical may use or disclose PHI for public health reasons in order to prevent or control disease, injury, or disability; or report births, deaths, suspected abuse or neglect, non- accidental physical injuries, reactions to medications or problems with products.
• Health Oversight Activities: Alpine Medical may use or disclose PHI to a health oversight agency for audits, investigations, inspections, or licensing purposes.
• Lawsuits and Disputes: Alpine Medical may use or disclose PHI in response to a court administrative order due to your involvement in a lawsuit or dispute. Alpine Medical may release PHI in response to a subpoena subject to all applicable legal requirements.
• Coroners, Medical Examiners, and Funeral Directors: Alpine Medical may use or disclose PHI to a coroner or medical examiner when requested.
• De-Identified Information: Alpine Medical may use or disclose PHI in a way that does not identify who you are.
• Marketing: Alpine Medical will not use your information for marketing purposes without your written authorization. Alpine Medical will not sell your PHI to another organization for marketing or any other purposes.

In situations where you are not capable of giving consent due to incapacitation or a medical emergency, Alpine Medical may, using our professional judgment, use or disclose PHI to a family member or friend if it is in your best interest.

Your PHI Privacy Rights
You have the following rights about PHI:

• Right to Inspect and Copy: With certain exceptions, you have the right to inspect and copy your health information. You may request an electronic copy of your records. You must make the request in writing. Alpine Medical reserves the right to charge a fee to cover the costs of labor, supplies, and mailing. Alpine Medical may deny your request to inspect and/or copy your records in certain circumstances. If you are denied access to your PHI, you may request that the denial be reviewed. The second reviewer will be a licensed health care provider not involved in the first decision to deny access.
• Right to Amend: You have the right to request that an amendment to your record be made if you think the information is incorrect or there is information missing. Your request must be in writing and must include a reason for the request. Alpine Medical may deny your request for an amendment if the information to be corrected was not originally created by Alpine Medical, is not part of PHI that we maintain, was not permitted to be inspected and/or copied, or is already accurate and complete. A copy of your amendment request will be put in your record even if we do not agree to amend the record itself.
• Right to a List of Disclosures: You have the right to an “accounting of disclosures” of your PHI. This is a list of disclosures of PHI about you for purposes other than treatment, payment, healthcare operations, and a limited number of special circumstances involving national security, correctional institutions, and law enforcement. The list will exclude any disclosures Alpine Medical has made based on your written authorization. To obtain this list, you must submit your request in writing to the Compliance Officer. It must state a time period which may not be longer than six years and may not include requests for information before to April 14, 2003. The request must indicate how you would like the information (paper or electronically). For list requests after the first one, Alpine Medical reserves the right to charge a fee for the costs of providing the lists.
• Right to Request Restrictions: You have the right to request a restriction or limitation on the use of your PHI. The request must be in writing and describe what information you wish to be restricted and to whom Alpine Medical may deny a request. If the request is approved, the restrictions may be terminated either in writing or verbally at any time in the future.
• Right to Request Restrictions to Health Plan: You have the right to request a restriction of disclosure to your health plan for treatments you pay cash for. The request must be in writing and describe what information you wish to be restricted and the name of your health plan. This restriction does not extend to follow-up care or disclosures authorized to another provider, unless the restriction request specifies. Alpine Medical does have the right to bill your health plan if Alpine Medical is unable to obtain payment from you.
• Right to Request Confidential Communications: You have the right that Alpine Medical communicates with you about your PHI in a certain way or at a certain location. For example, you may request that Alpine Medical contacts you only at work, or only by mail. The request must be in writing. No reason is necessary. We will accommodate all reasonable requests.
• Right to Receive Notification of a Breach: If there is a breach involving your PHI, Alpine Medical will contact you in writing with a description of the breach, the type of information involved, the steps you should take to protect yourself, a brief summary of what is being done and the person you can contact for further information.
• Right to File a Complaint: You have the right to file a complaint if you feel your privacy rights have been violated. You will not be penalized for filing a complaint. You may contact the Compliance Officer listed at the top of this notice, or the Office for Civil Rights at:

• Right to a Paper Copy of this Notice: You have the right to a paper copy of this notice at any time.