Assigning Privacy and Security Responsibilities
It is the policy of Associated Medical, Inc that specific individuals
within our workforce are assigned the responsibility of implementing
and maintaining the HIPAA Privacy and Security Rule's requirements.
Furthermore, it is the policy of Associated Medical, Inc that these
individuals will be provided sufficient resources and authority to fulfill
their responsibilities. At a minimum it is the policy of Associated
Medical, Inc that there will be one individual or job description designated
as the Privacy Official.
Uses and Disclosures of Protected Health Information
It is the policy of Associated Medical, Inc that protected health information
may not be used or disclosed except when at least one of the following
conditions is true:
1. The individual who is the subject of the information has authorized
the use or disclosure.
2. The individual who is the subject of the information has received
our Notice of Privacy Practices and acknowledged receipt of the Notice,
thus allowing the use or disclosure and the use or disclosure is for
treatment, payment or health care operations.
3. The individual who is the subject of the information agrees or
does not object to the disclosure and the disclosure is to persons involved
in the health care of the individual.
4. The disclosure is to the individual who is the subject of the information
or to HHS for compliance-related purposes.
5. The use or disclosure is for one of the HIPAA "public purposes"
(i.e. required by law, etc.).
Deceased Individuals
It is the policy of Associated Medical, Inc that privacy protections
extend to information concerning deceased individuals.
Notice of Privacy Practices
It is the policy of Associated Medical, Inc that a notice of privacy
practices must be published, that this notice and any revisions to it
be provided to all individuals at the earliest practicable time, and
that all uses and disclosures of protected health information be done
in accord with this organization's notice of privacy practices. We will
attempt to gain written acknowledgement of the receipt of the notice
from all individuals to whom we provide the notice of privacy practices
and, if we fail, will document our attempts to gain such acknowledgement.
Restriction Requests
It is the policy of Associated Medical, Inc that serious consideration
must be given to all requests for restrictions on uses and disclosures
of protected health information as published in this organization's
notice of privacy practices. It is furthermore the policy of this organization
that if a particular restriction is agreed to, then this organization
is bound by that restriction.
Minimum Necessary Disclosure of Protected Health Information
It is the policy of Associated Medical, Inc that (except for disclosures
made for treatment, payment or healthcare operations) all disclosures
of protected health information must be limited to the minimum amount
of information needed to accomplish the purpose of the disclosure. It
is also the policy of this organization that all requests for protected
health information (except requests made for treatment, payment or health
care operations) must be limited to the minimum amount of information
needed to accomplish the purpose of the request.
Access to Protected Health Information
It is the policy of Associated Medical, Inc that access to protected
health information must be granted to each employee or contractor based
on the assigned job functions of the employee or contractor. It is also
the policy of this organization that such access privileges should not
exceed those necessary to accomplish the assigned job function.
Access to Protected Health Information by the Individual
It is the policy of Associated Medical, Inc that access to protected
health information must be granted to the person who is the subject
of such information when such access is requested, or at the very least
within the timeframes required by the HIPAA Privacy Rule. It is the
policy of Associated Medical, Inc to inform the person requesting access,
of the location of protected health information if we do not physically
possess such PHI but have knowledge of its location.
Amendment of Incomplete or Incorrect Protected Health Information
It is the policy of Associated Medical, Inc that all requests for amendment
of incorrect protected health information maintained by this organization
will be considered in a timely fashion. If such requests demonstrate
that the information is actually incorrect, this organization will allow
amending language to be added to the appropriate document and this addition
will be done in a timely fashion. It is also the policy of this organization
that notice of such corrections will be given to any organization with
which the incorrect information has been shared.
Access by Personal Representatives
It is the policy of Associated Medical, Inc that access to protected
health information must be granted to personal representatives of individuals
as though they were the individuals themselves, except in cases of abuse
where granting said access might endanger the individual or someone
else. We will conform to the relevant custody status and the strictures
of state, local, case, and other applicable law when disclosing information
about minors to their parents.
Confidential Communications Channels
It is the policy of Associated Medical, Inc that confidential communications
channels be used, as requested by the individuals, to the extent possible.
Disclosure Accounting
It is the policy of Associated Medical, Inc that an accounting of all
disclosures subject to such accounting of protected health information
be given to individuals whenever such an accounting is requested.
Marketing Activities
This organization does not consider the communication of alternate forms
of treatment, or the use of products and services in treatment to be
marketing. Furthermore, this organization adheres to the HIPAA Privacy
Rule that communication made by us or a firm we use to the patient for
the purpose of education of health care wellness programs does not require
an Authorization.
Judicial and Administrative Proceedings
It is the policy of Associated Medical, Inc that information be disclosed
for the purposes of a judicial or administrative proceeding only when:
accompanied by a court or administrative order or grand jury subpoena;
when accompanied by a subpoena or discovery request that includes either
the authorization of the individual to whom the information applies,
documented assurances that good faith effort has been made to adequately
notify the individual of the request for their information and there
are no outstanding objections by the individual, or a qualified protective
order issued by the court. If a subpoena or discovery request is submitted
to us without one of those assurances, we will seek to notify the individual,
obtain his or her authorization, or obtain a qualified protective order
before we disclose any information. In no case will we disclose information
other than that required by the court order, subpoena, or discovery
request.
De-Identified Data and Limited Data Sets
It is the policy of Associated Medical, Inc to disclose de-identified
data only if it has been properly de-identified by a qualified statistician
or by removing all the relevant identifying data. We will make use of
limited data sets, but only after the relevant identifying data have
been removed and then only to organizations with whom we have adequate
data use agreements and only for research, public health, or health
care operations purposes..
Authorizations
It is the policy of Associated Medical, Inc that a valid authorization
will be obtained for all disclosures that are not for: treatment, payment,
health care operations, to the individual or their personal representative,
to persons involved with the individuals care, to business associates
in their legitimate duties, to facility directories or for public purposes.
This authorization will include all the mandatory elements and any authorizations
generated from outside this organization will be checked to see if they
are valid.
Complaints
It is the policy of Associated Medical, Inc that all complaints relating
to the protection of health information be investigated and resolved
in a timely fashion. Furthermore, it is the policy of this Associated
Medical, Inc that all complaints will be addressed to Paul D. Cantwell,
Privacy Official who will be duly authorized to investigate complaints
and implement resolutions if the complaint stems from a valid area of
non compliance with the HIPAA Privacy and Security Rule.
Prohibited Activities
It is the policy of Associated Medical, Inc that no employee or contractor
may engage in any intimidating or retaliatory acts against persons who
file complaints or otherwise exercise their rights under HIPAA regulations.
It is also the policy of this organization that no employee or contractor
may condition treatment, payment, enrollment or eligibility for benefits
on the provision of an authorization to disclose protected health information.
Responsibility
It is the policy of Associated Medical, Inc that the responsibility
for designing and implementing procedures to implement this policy lies
with the chief privacy officer (i.e. "CPO").
Verification of Identity
It is the policy of Associated Medical, Inc that the identity of all
persons who request access to protected health information be verified
before such access is granted.
Mitigation
It is the policy of Associated Medical, Inc that the effects of any
unauthorized use or disclosure of protected health information be mitigated
to the extent possible.
Safeguards
It is the policy of Associated Medical, Inc that appropriate physical
safeguards will be in place to reasonably safeguard protected health
information from any intentional or unintentional use or disclosure
that is in violation of the HIPAA Privacy Rule. These safeguards will
include physical protection of premises and PHI, technical protection
of PHI maintained electronically and administrative protection. These
safeguards will extend to the oral communication of PHI. These safeguards
will extend to PHI that is removed from this organization.
Business Associates
It is the policy of Associated Medical, Inc that business associates
must be contractually bound to protect health information to the same
degree as set forth in this policy. It is also the policy of this organization
that business associates who violate their agreement will be dealt with
first by an attempt to correct the problem, and if that fails by termination
of the agreement and discontinuation of services by the business associate.
Training and Awareness
It is the policy of this Associated Medical, Inc that all members of
our workforce have been trained by the compliance date on the policies
and procedures governing protected health information and how Associated
Medical, Inc complies with the HIPAA Privacy and Security Rule. It is
also the policy of Associated Medical, Inc that new members of our workforce
receive training on these matters within a reasonable time after they
have joined the workforce. It is the policy of Associated Medical, Inc
to provide training should any policy or procedure related to the HIPAA
Privacy and Security Rule materially change. This training will be provided
within a reasonable time after the policy or procedure materially changes.
Furthermore, it is the policy of Associated Medical, Inc that training
will be documented indicating participants, date and subject matter.
Sanctions
It is the policy of Associated Medical, Inc that sanctions will be in
effect for any member of the workforce who intentionally or unintentionally
violates any of these policies or any procedures related to the fulfillment
of these policies.
Retention of Records
It is the policy of Associated Medical, Inc that the HIPAA Privacy Rule
records retention requirement of six years will be strictly adhered
to. All records designated by HIPAA in this retention requirement will
be maintained in a manner that allows for access within a reasonable
period of time. This records retention time requirement may be extended
at this organization's discretion to meet with other governmental regulations
or those requirements imposed by our professional liability carrier.
Cooperation with Privacy Oversight Authorities
It is the policy of Associated Medical, Inc that oversight agencies
such as the Office for Civil Rights of the Department of Health and
Human Services be given full support and cooperation in their efforts
to ensure the protection of health information within this organization.
It is also the policy of this organization that all personnel must cooperate
fully with all privacy compliance reviews and investigations.