OB-GYN ASSOCIATES, P.C. NOTICE OF PRIVACY PRACTICES

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.

Our practice is dedicated to maintaining the privacy of your individually protected health information (sometimes referred to as “PHI”). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this Notice of our legal duties and the privacy practices that we maintain in our practice concerning your protected health information. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time. The terms of this Notice apply to all records containing your protected health information that is created or retained by our practice.

Your Information. Your Rights. Our Responsibilities.

Your Rights

You have the right to:

  • Get a copy of your paper or electronic medical record
  • Correct your paper or electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we have shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

  • Tell family and friends about your condition
  • Provide disaster relief
  • Provide mental health care
  • Market our services and sell your information
  • Raise funds

Our Uses and Disclosures

We may use and share your information as we:

  • Treat you
  • Run our organization
  • Bill for your services
  • Help with public health and safety issues
  • Do research
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Address workers’ compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your medical record and other health information, including your billing records, we have about you.
  • You must submit your request in writing to Manager – Administrative Services, in order to inspect and/or obtain a copy of your protected health information. For any medical information maintained in your electronic medical record, your written request may include a request to provide a copy in electronic form. We will provide the information to you in the form and format you requested, assuming it is readily producible. If we cannot readily produce the record in the form and format you request, we will produce it in another readable electronic form to which we agree. In addition, we will transmit information from your electronic medical record directly to a person or entity of your choosing if the request is made in writing and you sign an authorization.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request.
  • Our practice may charge a reasonable, cost-based fee for the labor for copying, supplies for creating the paper copy, or electronic media (e.g., CD-ROM), and postage. We may also charge a reasonable cost-based fee for preparing an explanation or summary of the protected health information if you request an explanation/summary and agree to the fee that may be charged.
  • Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.


Ask us to correct your medical record
  • You can ask us to correct health information about you that you think is incorrect or incomplete, as long as the information is kept by or for our practice.
  • To request an amendment, your request must be made in writing and submitted to Manager – Risk/QA/Compliance. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the protected health information kept by or for the practice; (c) not part of the protected health information which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
  • We may say “no” to your request, but we will tell you why in writing within 60 days.

Request confidential communications
  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • In order to request a type of confidential communication, you must make a written request to the Manager – Administration Services, specifying the requested method of contact, or the location where you wish to be contacted. We will say “yes” to all reasonable requests. You do not need to give a reason for your request.

Ask us to limit what we use or share
  • You can ask us not to use or share certain health information for treatment, payment, or our operations. You have the right to request that we restrict our disclosure of your protected health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer, i.e. any third party payer, including Medicare, Medicaid or private insurers. We will say “yes” unless a law requires us to share that information.
  • For all other disclosures, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
  • In order to request a restriction in our use or disclosure of your protected health information, you must make your request in writing to Manager – Administrative Services. Your request must describe in a clear and concise manner: (1) the information you wish restricted, (2) whether you are requesting to limit our practice’s use, disclosure or both; and (3) to whom you want the limits to apply.

Get a list of those with whom we have shared information
  • You can ask for a list (accounting) of the times we have shared your health information for six (6) years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
  • In order to obtain an accounting of disclosures, you must submit your request in writing to Manager – Risk/QA/Compliance. All requests for an “accounting of disclosures” must state a time period. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Get 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. To obtain a paper copy of this notice, contact the front office Reception Staff.
  • We will provide you with a paper copy promptly.


Choose 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.
  • We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
  • You can complain if you feel we have violated your rights by contacting us using the information on page 8.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
  • We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation

If you are not able to tell us your preference – for example if you are unconscious – we may go ahead and 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.

In these cases we never share your information unless you give us written permission:
  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

In the case of fundraising:
  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you
Our practice may use your protected health information to treat you. We can use your health information and share it with other professionals who are treating you. Many of the people who work for our practice – including, but not limited to, our doctors, mid-level providers, nurses, laboratory technicians, and ultrasound technicians – may use or disclose your protected health information in order to treat you or to assist others in your treatment. We may also disclose your protected health information to other health care providers for purposes related to your treatment.

Examples: (1) A doctor treating you for an injury asks another doctor about your overall health condition. (2) You are being treated for a gynecological cancer, we may disclose your protected health information to Mayo Clinic for a consult. (3) We might use your protected health information in order to write a prescription for you, or we might disclose your protected health information to a pharmacy when we order a prescription for you. Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary. We may disclose your protected health information to other health care providers and entities to assist in their health care operations.

Examples: (1) We use health information about you to manage your treatment and services. (2) We may use your protected health information to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. (3) We may use and disclose your protected health information to contact you and remind you of an appointment.Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities for the services and items you may receive from us. We also may use and disclose your protected health information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your protected health information to bill you directly for services and items. We may disclose your protected health information to other health care providers and entities to assist in their billing and collection efforts.

Example: We may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment.

How else can we use or share your health information?

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. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues
We can share health information about you for certain situations such as:

  • Maintaining vital records, such as births and deaths
  • Preventing disease, including notifying a person regarding a potential risk for spreading or contracting a disease or condition, or notifying a person regarding potential exposure to a communicable disease
  • Helping with product or device recalls
  • Reporting adverse reactions to medications or devices
  • Reporting suspected abuse, neglect, or domestic violence to the appropriate government agency(ies) and authority(ies)
  • Preventing or reducing a serious threat to anyone’s health or safety
  • Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
Do research
We may disclose your protected health information to help conduct research. Research may involve finding a cure for an illness or helping to determine how effective a treatment is.

Respond to organ and tissue donation requests
While generally not relevant to our practice, if applicable, we can share health information about you with organ procurement organizations.

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.

Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
  • For workers’ compensation claims; we may disclose protected health information at your employer’s request regarding a work-related injury.
  • For law enforcement purposes or with a law enforcement official. We may release protected health information if asked to do so by a law enforcement official:
  • Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
  • Regarding criminal conduct at our office(s)
  • Concerning a death we believe has resulted from criminal conduct
  • In response to a warrant, summons, court order, subpoena or similar legal process
  • To identify/locate a suspect, material witness, fugitive or missing person
  • In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)
  • If a patient is being treated for a wound of violence – or some injury believed to have been caused by some violent act. i.e. gunshot wound, stabbing - of which it is our duty to report.
  • If federal, state, or local laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
  • With health oversight agencies for activities authorized by law. We may disclose your protected health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example:
  • investigations, inspection, audits, surveys, licensure and disciplinary actions;
  • civil, administrative, and criminal procedures or actions;
  • or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
  • Example: We may disclose protected health information to the Food and Drug Administration, state Medicaid fraud control, or the U.S. Department of Health and Human Service Office for Civil Rights.
    • For special government functions such as military, national security, and presidential protective services
    Respond to lawsuits and legal actions
    We can share health information about you in response to a court or administrative order.

    We also may disclose your protected health information in response to a discovery request, subpoena, or other lawful process by another party involved in a dispute, but only if they or we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

    In addition, we may disclose medical information to the opposing party in any lawsuit of administrative proceeding where you have put your physical or mental condition at issue once you have signed a written authorization to release the information.

    With an authorization
    Some uses and disclosures of your medical information can be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization anytime, in writing, unless we have relied on the use or disclosure indicated in the authorization.

    Examples of those uses and disclosures that may only be made with your written authorization:
    • We will obtain your authorization for uses and disclosures of your health information that are not described in this Notice.
    • We will disclose AIDS or HIV-related information, or substance abuse treatment information only with written authorization as required by applicable state law and/or federal regulations unless the law expressly permits otherwise.
    • We will provide mental health information only if you have signed an authorization consistent with Iowa law.
    • We will not use or disclose your protected health information for marketing purposes without your authorization. Moreover, if we will receive any financial remuneration from a third party in connection with marketing, we will tell you that in the authorization form.
    • We will not sell your protected health information to third parties without your authorization. Any such authorization will disclose that we will receive compensation in the transaction.

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 occurs that may have compromised the privacy or security of your information.
  • 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. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

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. Any revision or amendment to this Notice will be effective for all of your records that we have created or maintained in the past, and for any of your records that we may create or maintain in the future. We will post a copy of our current Notice in our office in a visible location at all times, and you may request a paper copy of our most current Notice at any time. In addition, the current version of our Notice will be posted on our website at www.ob-gynassoc.com.

Complaints and Questions

If you believe your privacy rights have been violated, you may file a complaint with the Manager of Risk/Quality/Compliance or with the Secretary of the U.S. Department of Health and Human Services.

To file a complaint with OB-GYN Associates, P.C., notify the Manager – Risk/Quality/Compliance at the contact information listed below. You may also contact the Practice Administrator listed below. You will not be penalized for filing a complaint and your care will not be compromised. If you have questions about this Notice, or have any complaints about our privacy practices, please contact the Practice Administrator.

OB-GYN Associates, P.C.
Manager – Risk/Quality/Compliance
855 A Ave NE Suite 200
Cedar Rapids, IA 52402
Phone: 319-368-5537
Email: sheilascheib@ob-gynassoc.com


OB-GYN Associates, P.C.
Practice Administrator
855 A Ave NE Suite 200
Cedar Rapids, Iowa 52402
Phone: 319-368-5500
Email: tomkaloupek@ob-gynassoc.com

Additional Contact Information:

For: Requesting an Accounting of Disclosures
Amending Your Medical Record
Contact: Manager – Risk/QA/Compliance, see above

For: Inspection and Copying of your Medical Record
Inspection and Copying of your Billing Records
Confidential Communications/Requesting a Specific Type of Communications
Requesting a Restriction
Revoking your Permission to Disclose your Medical Information
Contact: Manager – Administrative Service
OB-GYN Associates, P.C.
855 A Ave NE
Cedar Rapids, IA 52402
Phone: 319-368-5556