MONTGOMERY CANCER CENTER , LLC
CARMICHAEL IMAGING, LLC
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.
This Privacy Notice covers an Affiliated Covered Entity ("ACE") made up of the following entities and components:
Montgomery Cancer Center , LLC
4145 Carmichael Road
Montgomery , AL 36106
Montgomery Cancer Center , LLC – East
7085 Sydney Curve
Montgomery , AL 36117
Montgomery Cancer Center , LLC – Selma
1023 Medical Center Parkway
Selma , AL 36701
Montgomery Cancer Center , LLC – Troy
Edge Regional Medical Center
1330 Highway 231 South
Troy , AL 36081
Carmichael Imaging, LLC
4147 Carmichael Blvd.
Montgomery , AL 36106-2801
Montgomery Breast Center , LLC
- A Division of Carmichael Imaging, LLC
4147 Carmichael Blvd.
Montgomery , AL 36106-2801
Montgomery Cancer Center, LLC (MCC) and Carmichael Imaging, LLC (CI) are required under the federal health care privacy rules (the "Privacy Rules"), to protect the privacy of your health information, which includes information about your health history, symptoms, test results, diagnoses, treatment, and claims and payment history (collectively, "Health Information"). MCC/CI is also required to provide you with this Privacy Notice regarding our legal duties, policies and procedures to protect and maintain the privacy of your Health Information. MCC/CI is required to follow the terms of this Privacy Notice unless (and until) it is revised. MCC/CI reserves the right to change the terms of this Privacy Notice and to make the new notice provisions effective for the Health Information that MCC/CI maintains and uses, as well as for any Health Information that MCC/CI may receive in the future. Should the terms of this Privacy Notice change, MCC/CI will make a revised copy of the notice available to you. Revised Privacy Notices will be available at our office for individuals to take with them and MCC/CI will post a copy of revised Privacy Notices in a prominent location in our office. Privacy Notices will also be posted and available electronically on MCC's web site.
Permitted Uses and Disclosures of Your Health Information.
1) General Uses and Disclosures. Under the Privacy Rules, MCC/CI is permitted to use and disclose your Health Information for the following purposes, without obtaining your permission or Authorization:
2) Uses and Disclosures Which Require Patient Opportunity to Verbally Agree or Object. Under the Privacy Rules, MCC/CI is permitted to use and disclose your Health Information: (i) for the creation of facility directories, (ii) to disaster relief agencies, and (iii) to family members, close personal friends or any other person identified by you, if the information is directly relevant to that person's involvement in your care or treatment. Except in emergency situations, you will be notified in advance and have the opportunity to verbally agree or object to this use and disclosure of your Health Information.
3) Uses and Disclosures Which Require Written Authorization. As required by the Privacy Rules, all other uses and disclosures of your Health Information (not described above) will be made only with your written Authorization. For example, in order to disclose your Health Information to a company for marketing purposes, MCC/CI must obtain your Authorization. Under the Privacy Rules, you may revoke your Authorization at any time. The revocation of your Authorization will be effective immediately, except to the extent that: MCC/CI has relied upon it previously for the use and disclosure of your Health Information; the Authorization was obtained as a condition of obtaining insurance coverage where other law provides the insurer with the right to contest a claim under the policy or the policy itself; or where your Health Information was obtained as part of a research study and is necessary to maintain the integrity of the study.
You have the following rights concerning your Health Information:
1) Right to Inspect and Copy Your Health Information. Upon written request, you have the right to inspect and copy your own Health Information contained in a designated record set, maintained by or for us. A "designated record set" contains medical and billing records and any other records that MCC/CI uses for making decisions about you. However, MCC/CI is not required to provide you access to all the Health Information that MCC/CI maintains. For example, this right of access does not extend to psychotherapy notes, or information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative proceeding. Where permitted by the Privacy Rules, you may request that certain denials to inspect and copy your Health Information be reviewed. If you request a copy or summary of explanation of your Health Information, MCC/CI may charge you a reasonable fee for copying costs, including the cost of supplies and labor, postage, and any other associated costs in preparing the summary or explanation.
2) Right to Request Restrictions on the Use and Disclosure of Your Health Information. You have the right to request restrictions on the use and disclosure of your Health Information for treatment, payment and health care operations, as well as disclosures to persons involved in your care or payment for your care, such as family members or close friends. MCC/CI will consider, but do not have to agree to, such requests.
3) Right to Request an Amendment of Your Health Information. You have the right to request an amendment of your Health Information. MCC/CI may deny your request if MCC/CI determines that you have asked MCC/CI to amend information that: was not created by MCC, unless the person or entity that created the information is no longer available; is not Health Information maintained by or for us; is Health Information that you are not permitted to inspect or copy; or MCC/CI determines that the information is accurate and complete. If MCC/CI disagree with your requested amendment, MCC/CI will provide you with a written explanation of the reasons for the denial, an opportunity to submit a statement of disagreement, and a description of how you may file a complaint.
4) Right to an Accounting of Disclosures of Your Health Information. You have the right to receive an accounting of disclosures of your Health Information made by MCC/CI within six (6) years prior to the date of your request. The accounting will not include: disclosures related to treatment, payment or health care operations; disclosures to you; disclosures based on your Authorization; disclosures that are part of a Limited Data Set; incidental disclosures; disclosures to persons involved in your care or payment for your care; disclosures to correctional institutions or law enforcement officials; disclosures for facility directories; or disclosures that occurred prior to April 14, 2003.
5) Right to Alternative Communications. You have the right to receive confidential communications of your Health Information by a different means or at a different location than currently provided. For example, you may request that MCC/CI only contact you at home or by mail.
6) Right to Receive a Paper Copy of this Privacy Notice. You have the right to receive a paper copy of this Privacy Notice upon request, even if you have agreed to receive this Privacy Notice electronically.
If you want to exercise any of these rights, please contact our Privacy Officer. All requests must be submitted to MCC/CI in writing on a designated form (which MCC/CI will provide to you), and returned to the attention of our Privacy Officer at the address below.
Contact Information and How to Report a Privacy Rights Violation.
If you have questions and/or would like additional information regarding the uses and disclosures of your Health Information, you may contact our Privacy Officer at:
Address: Montgomery Cancer Center , LLC
4145 Carmichael Road
Montgomery , AL 36106
Attn: Privacy Officer
Telephone: (334) 273-7000
Fax: (334) 273-2290
If you believe that your privacy rights have been violated or that we have violated our own privacy practices, you may file a complaint with us. You may contact the Privacy Officer at the address or phone number listed above or you may file a confidential complaint by calling the Compliance Hotline (1-800-826-6762). If calling the Compliance Hotline, you will be greeted by an independent professional who will confidentially relay your concern to the Compliance Officer for investigation. You may also file a complaint with the Secretary of DHHS at Region IV, Office of Civil Rights, U.S. Department of Health and Human Services at Atlanta Federal Center , Suite 3B70 , 61 Forsyth Street, S.W. , Atlanta , Georgia , 30303-8909, Voice Phone (404) 562-7886, Fax (404) 562-7881, TDD (404) 331-2867. Complaints filed directly with the Secretary must be made in writing, name us, describe the acts or omissions in violation of the Privacy Rules or our privacy practices, and must be filed within 180 days of the time you knew or should have known of the violation. There will be no retaliation for filing a complaint.
The Effective Date of this Privacy Notice is April 14, 2003.
© Montgomery Cancer Center, 4145 Carmichael Road Montgomery, AL 36106