THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFOMRATION. PLEASE REVIEW IT CAREFULLY.
Five Valleys Urology is committed to maintaining the privacy and confidentiality of all patient information. You have the right to privacy concerning your health care. All care and counseling received from Five Valleys Urology will be kept strictly confidential, except as required by law. Our Privacy Notice and policy on the Disclosure of Information are provided to acquaint you with your rights as a patient.
The privacy of your medical record is safeguarded. Information is available to any clinician, attorney or medical practitioner with your written authorization. If you would like to disclose information contained in your medical record to a third party, you must complete a written Medical Records/X-Ray Release Authorization form.
Certain information is obtained and kept whenever a person is treated at or referred from the medical practice of Five Valleys Urology. The information which you are requested to supply is necessary to assure your accurate identification, continuity of medical care and payment when appropriate. It is mandatory that you supply all requested information unless noted as optional. Failure to do so may affect our ability to provide optimal care of your health needs.
Your record is maintained at the Garden City Medical Building, 601 West Spruce Street, Suite G, Missoula, MT 59802 by Medical Records staff, under the supervision of the Business Manager, who may be contacted at (406) 728-3366. Within the limits of the law, you may review the information you provide and which we develop during your care. Information is also kept in an electronic database with high level security and restricted access.
The privacy of your record will be safeguarded. Information is available to any clinician, attorney, or medical facility with your written authorization. It will be available without your authorization to Five Valleys Urology and the assistants who may be involved in providing or reviewing your care. Information will be transmitted to State and Federal governmental agencies if required by law.
Pursuant to the Federal Privacy Act of 1974 and Regulation 4, Section 404, 1256, Code of Federal Regulations, under section 218, Title II of the Social Security Act, as amended, you are also hereby notified that disclosure of your social security number is mandatory. It is used to verify your identity in the medical care and payment system.
Disclosure of Information
Disclosure of information contained in the medical record may be made to a third party by authorized personnel once the legitimacy of the request has been established, and a valid written authorization is obtained from the patient.
Information is routinely disclosed from Medical Records by providing the third party with photocopies of the requested information. The third party may also request to review the medical record in person in the presence of the Business Manager during normal business hours. All disclosures will be documented in the disclosure log. A copy of the Business Associate Agreement will accompany all disclosures to third parties.
Authorization for disclosure is not required:
- When the health and safety of the individual is in jeopardy, i.e. in an emergency, to another facility or physician treating the individual via telephone.
- Upon direct transfer of the individual’s care to another facility.
- On court order or subpoena (under certain circumstances).
- For examination by an accrediting or licensing agency.
- For information provided to the Health Department (City, County, or State), as required by law regarding communicable disease and vital statistics.
- For review by Industrial Accident Boards.
- By the Food and Drug Administration during and official investigation.
- For police during an official criminal investigation.
- For Blue Cross and Blue Shield when acting as intermediary for government-sponsored programs.
- For practice legal counsel in all cases involving litigation against the practice.
- For the Medical Examiner’s Office.
Authorization for disclosure is required:
- For licensed medical or psychiatric personnel not consulting or on Five Valleys Urology’s staff, but providing care to the individual.
- For facilities providing care to the individual, other than by direct referral by Five Valleys Urology.
- For lawyers.
- For insurance companies.
- For government agencies, unless authorized by law.
- For schools.
- For employers.
- For Worker’s Compensation proceedings.
Valid authorization must be:
- In writing.
- Addressed to Five Valleys Urology.
- Dated within thirty days of our receipt of consent or within the time limit stipulated by the patient and not dated prior to the beginning of treatment.
- Designate the person, company, or agency to whom the information is to be disclosed.
- Specify what information is to be disclosed, and list any limitations (such as dates of visits to be included).
- Signed by the patient, as verified by matching the signature against the signature on the health form. If the patient is incompetent, it must be signed by the conservator of the estate or the next of kin.
- An original, unless not available, and then a legible photocopy.
The authorization will be filed in the medical folder. If a photocopy service reproduces the medical record upon presentation of a valid authorization signed by the patient, the representative will be required to sign and date the bottom of the authorization.