Effective date: January 1, 2016

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Please review this notice carefully

A. Our commitment to your privacy:
Dr. Brian Teliho is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the 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 concerning your PHI. By federal and state law, we must follow the terms of the Medical Information Privacy Policy that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

  • How we may use and disclose your PHI,
  • Your privacy rights in your PHI,
  • Our obligations concerning the use and disclosure of your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by Brian Teliho, MD. We reserve the right to revise or amend this privacy policy. Any revision or amendment to this notice will be effective for all of your records 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 on our website, and you may request a copy of our most current Notice at any time.

B. If you have questions about this Notice, please contact us.

C. We may use and disclose your PHI in the following ways:
The following categories describe the different ways in which we may use and disclose your PHI.

1. Services. We may use your PHI when providing service to you. For example, we may use your PHI when requesting and reviewing your medical records from others. Many of the people who work for our practice – including, but not limited to, Dr. Teliho – may use or disclose your PHI in order to evaluate you or to assist others in your treatment. Additionally, we may disclose your PHI to others
who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your evaluation and future treatment.

2. Payment. We may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care
providers and entities to assist in their billing and collection efforts.

3. Health care operations. We may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, we may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities. We may disclose your PHI to other health care providers and entities to
assist in their health care operations.

4. Appointment reminders. We may use and disclose your PHI to contact you and remind you of an appointment.

5. Treatment options. We may use and disclose your PHI to inform you of potential treatment options or alternatives.

6. Health-related benefits and services. We may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.

7. Disclosures required by law. We will use and disclose your PHI when we are required to do so by federal, state or local law.

D. Use and disclosure of your PHI in certain special circumstances:
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public health risks. We may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

  • Maintaining vital records, such as births and deaths,
  • Reporting child abuse or neglect,
  • Preventing or controlling disease, injury or disability,
  • Notifying a person regarding potential exposure to a communicable disease,
  • Notifying a person regarding a potential risk for spreading or contracting a disease or condition,
  • Reporting reactions to drugs or problems with products or devices,
  • Notifying individuals if a product or device they may be using has been recalled,
  • Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or
    neglect of an adult patient (including domestic violence); however, we will only disclose this
    information if the patient agrees or we are required or authorized by law to disclose this information,
  • Notifying your employer under limited circumstances related primarily to workplace injury or illness
    or medical surveillance.

2. Health oversight activities. We may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, 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.

3. Lawsuits and similar proceedings. We may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain
an order protecting the information the party has requested.

4. Law enforcement. We may release PHI 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,
  • Concerning a death we believe has resulted from criminal conduct,
  • Regarding criminal conduct at our offices,
  • 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).

5. Serious threats to health or safety. We may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

6. Military. We may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

7. National security. We may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations.

8. Inmates. We may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

9. Workers’ compensation. We may release your PHI for workers’ compensation and similar programs.

E. Your rights regarding your PHI:

You have the following rights regarding the PHI that we maintain about you:

1. Confidential communications. You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Dr. Teliho specifying the requested method of
contact, or the location where you wish to be contacted. We will accommodate reasonable requests. You do not need to give a reason for your request.

2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI 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;
however, 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 aid you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Dr. Teliho. Your request must describe in a clear and concise fashion:

  • The information you wish restricted,
  • Whether you are requesting to limit our use, disclosure, or both,
  • To whom you want the limits to apply.

3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including billing records, but not including psychiatric notes. You must submit your request in writing to Dr. Teliho in order to inspect and/or obtain a copy of your PHI. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your
request. We 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.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by Dr. Teliho. To request an amendment, your request must be made in writing and submitted to us. You must provide us with a reason that supports your request for amendment. We 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 PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice.

5. Accounting of disclosures. All of our clients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of routine management is not required to be documented – for example, Dr. Teliho sharing
information with another covering physician; or the billing department using your information to process payment. In order to obtain an accounting of disclosures, you must submit your request in writing. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before June 15, 2015. We will notify you of any costs involved with requests, and you may withdraw your request before you incur any costs.

6. Right to a copy of this notice. You are entitled to receive a copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, contact Dr. Teliho.

7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with us directly, contact Dr. Teliho. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to provide an authorization for other uses and disclosures. We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time, in writing. After you revoke your authorization, we will no longer use or disclose
your PHI for the reasons described in the authorization. Please note: we are required to retain copies of your medical records.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact Dr. Teliho.