NOTICE OF PRIVACY PRACTICES
Effective Date: 4/14/03
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.
If you have any questions about this notice, please contact the Privacy Officer at
901-747-0040 during regular business hours.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal.
We are committed to protecting medical information about you. This notice will tell
you about the ways in which we may use and disclose protected health information
about you to carry out treatment, payment or health care operations and for other
purposes that are required or permitted by law. It also describes your rights and
certain obligations we have regarding the use and disclosure of your protected
Your “protected health information” means any of your written and oral health
information, including demographic data that can be used to identity you. This is
health information that is created or received by your health care provider, and that
relates to your past, present or future physical or mental health or condition.
Mays and Schnapp Pain Clinic and Rehabilitation Center and Pain Clinic
Associates, P.C. (referred to in this document as “the practice”) are required by law:
• to keep private protected health information that identifies you;
• to give you this notice of our legal duties and privacy practices with respect to
protected health information about you; and
• to follow the terms of the Notice of Privacy Rights currently in effect.
HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION
The following categories describe different ways that we use and disclose protected
health information. For better understanding, we have provided some examples in
each category. Not every use or disclosure in a category will be listed. However, all
of the ways we are permitted to use and disclose information will fall within one of
• For Treatment. We may use protected health information about you to
provide, coordinate, or manage your health care and any related services. We
may disclose protected health information about you to doctors, nurses,
technicians, or other personnel who are involved in taking care of you. For
example, we may share protected health information about you in order to
coordinate the different things you need, such as prescriptions, lab work and x-
rays. We may disclose protected health information about you to others
involved in your care, such as family members assisting you or other health
care providers, such as other treating physicians or medical equipment
providers. In some cases, we may also disclose your protected health
information to an outside treatment provider for purposes of the treatment
activities of the other provider. We also may use your protected health
information to contact you to check that you are progressing in your recovery.
• For Payment. We will use and disclose protected health information about
you so that the treatment and services you receive may be billed to and
payment may be collected from you, a health plan or a third party. For
example, we may disclose protected health information to your health plan to
determine whether you are eligible for benefits. We may need to give your
health plan information about treatment you received so your health plan will
pay us or reimburse you for the treatment. We may also tell your health plan
about a procedure you are going to receive to obtain prior approval or to
determine whether your plan will cover the procedure. In order to get payment
for services you receive, we may also need to disclose your protected health
information to your health plan to demonstrate the medical necessity of the
services or, as required by your health plan.
• For Health Care Operations. We may use and disclose protected health
information about you for the practice’s operations. These uses and disclosures
are necessary to run the practice and make sure that all of our patients receive
quality care. For example, we may use protected health information to review
our treatment and services and to evaluate the performance of our staff in
caring for you. We may also use protected health information for review and
auditing, including compliance reviews, medical reviews, legal services and
maintaining compliance programs. In certain situations, we may disclose
patient information to another provider or health plan for their health care
• Patient Satisfaction Surveys. We may use a limited amount of information
about you to conduct patient satisfaction surveys by telephone and written
• Health Awareness Materials. We may use your demographic information to
send general health information to you to create awareness in the community
of important health topics.
• Personal Representatives. If you or a court has authorized another
individual to act on your behalf, we will share information regarding your
treatment with your personal representative unless we believe that the
sharing of information would jeopardize your health or safety.
• Appointment Reminders. We may use and disclose protected health
information to contact you as a reminder that you have an appointment for
treatment or medical care. This practice includes contacting you by telephone.
• Treatment Alternatives. We may use and disclose protected health
information to tell you about or recommend possible treatment options or
alternatives that may be of interest to you. This includes reviewing your
protected health information to see if you meet the criteria to be eligible to
participate in clinical trials.
• Health-Related Benefits and Services. We may use and disclose protected
health information to tell you about health-related benefits or services that
may be of interest to you.
• Individuals Involved in Your Care or Payment for Your Care. We may
release protected health information about you to a friend or family member
who is involved with your medical care or payment for services, unless you
inform us that you object to such disclosure. (However, you may not use such
an objection to avoid payment for services by a responsible party.)
• As Required By Law. We will disclose protected health information about
you when required to do so by federal, state or local law.
• To Avert a Serious Threat to Health or Safety. We may use and disclose
protected health information about you when necessary to prevent a serious
threat to your health and safety or the health and safety of the public or
another person. Any disclosure, however, would only be to someone able to
help prevent the threat.
• Access by Parents. Some state laws concerning minors permit or require
disclosure of protected health information to parents, guardians, and persons
acting in a similar legal status. We will act consistently with the law of the
state where the treatment is provided and will make disclosures following such
• Military and Veterans. If you are a member of the armed forces, we may
release protected health information about you as required by military
command authorities. We may also release protected health information about
foreign military personnel to the appropriate foreign military authority.
• Workers' Compensation. The practice may release protected health
information about you for workers' compensation or similar programs. These
programs provide benefits for work-related injuries or illness.
• Medical Surveillance of the Workplace. If you are an employee who is
being evaluated at the request of your employer for medical surveillance of the
workplace or in relation to a work-related illness or injury, we may share
information obtained from such evaluation with your employer.
• Public Health Risks. We may disclose protected health information about
you for public health activities. These activities generally include the
• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report suspected child or adult abuse or neglect;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk
for contracting or spreading a disease or condition;
• to notify the appropriate government authority if we believe a patient has
been the victim of abuse, neglect or domestic violence. We will only make
this disclosure if you agree or when required or authorized by law.
• Health Oversight Activities. We may disclose protected health information
to a health oversight agency for activities authorized by law. These oversight
activities include, for example, audits, investigations, inspections, and
licensure. These activities are necessary for the government to monitor the
health care system, government programs, and compliance with civil rights
and other laws, regulations, and regulatory advice. We may also disclose
protected health information to lawyers or consultants who are providing
services to this medical practice or the individual physicians in the practice or
related entities regarding a legal or regulatory matter.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we
may disclose protected health information about you in response to a court or
administrative order. We may also disclose protected health information about
you in response to a subpoena, discovery request, or other lawful process by
someone else involved in the dispute, but only if we receive written assurances
that the party seeking your protected health information has made efforts to
tell you about the request or to obtain an order protecting the information
requested. We may use your protected health information to defend a legal
action against this medical practice or the physicians in the practice or other
related legal entity.
• Law Enforcement. We may release protected health information if asked to
do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• Under certain limited circumstances, when you are the victim of a crime;
• About a death we believe may be the result of criminal conduct;
• As required by law for reporting certain types of wounds or other physical
• In emergency circumstances to report a crime; the location of the crime or
victims; or the identity, description or location of the person who committed
• Coroners, Medical Examiners and Funeral Directors. We may release
protected health information to a coroner or medical examiner. This may be
necessary, for example, to identify a deceased person or determine the cause of
death. We may also release protected health information about patients of the
practice to funeral directors as necessary to carry out their duties. If you are an
organ donor, protected health information may be used and disclosed for
cadaveric organ, eye or tissue donation purposes.
• National Security and Intelligence Activities. We may release protected
health information about you to authorized federal officials for intelligence,
counterintelligence, and other national security activities authorized by law.
• Protective Services for the President and Others. We may disclose
protected health information about you to authorized federal officials so they
may provide protection to the President, other authorized persons or foreign
heads of state or conduct special investigations.
• Inmates. If you are an inmate of a correctional institution or under the
custody of a law enforcement official, we may release protected health
information about you to the correctional institution or law enforcement
official. This release would be necessary (1) for the institution to provide you
with health care; (2) to protect your health and safety or the health and safety
of others; or (3) for the safety and security of the correctional institution.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU:
You have the following rights regarding protected health information we maintain
• Right to Inspect and Copy. You have the right to inspect and copy protected
health information used to make decisions about your care. Usually, this
generally includes medical and billing records.
To inspect and copy protected health information used to make decisions about
you, you must submit your request in writing to the Privacy Officer. If you
request a copy of the information, we may charge a fee for the costs of copying,
mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain, limited
circumstances. For example, under federal law you may not inspect or copy
the following records; psychotherapy notes; information compiled in reasonable
anticipation of, or use in, a civil, criminal, or administrative action or
proceeding, and protected health information that is subject to law that
prohibits access to protected health information. If you are denied access to
medical information, you may request that the denial be reviewed.
Please contact our Privacy Contact if you have questions about access to your
• Right to Amend. If you feel that protected health information we have about
you is incorrect or incomplete, you may ask us to amend the information. You
have the right to request an amendment for as long as the information is kept
by or for the practice.
To request an amendment, your request must be made in writing and
submitted to the Privacy Officer. In addition, you must provide a reason that
supports your request.
We may deny your request for an amendment if it is not in writing or does not
include a reason to support the request. If we deny your request, you have a
right to file a statement of disagreement with us. We may prepare a rebuttal to
your statement and will provide you with a copy of any such rebuttal. In
addition, we may deny your request if you ask us to amend information that:
• Was not created by us, unless the person or entity that created the
information is no longer available to make the amendment;
• Is not part of the protected health information kept by or for this medical
• Is not part of the information which you would be permitted to inspect and
• Is accurate and complete.
• Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of
protected health information about you for reasons other than treatment,
payment or health care operations. We are also not required to account for
disclosures that you requested, disclosures that you agreed to by signing an
authorization form, to friends or family members involved in your care, or
certain other disclosures we are permitted to make without your authorization.
For example, an accounting of disclosures would include disclosures that we
are required by law to make, such as in response to a court order.
To request this accounting of disclosures, you must submit your request in
writing to the Privacy Officer. Your request must state a time period, which
may not be longer than six years and may not include dates before April 14,
2003. The first list you request within a 12 month period will be free. For
additional lists, we may charge you for the costs of providing the list. We will
notify you of the cost involved and you may choose to withdraw or modify your
request at that time before any costs are incurred.
• Right to Request Restrictions. You have the right to request a restriction
or limitation on the protected health information we use or disclose about you
for treatment, payment or health care operations. You may also request that
we not disclose your health information to family members or friends who may
be involved in your care or for notification purposes as described in this Notice
of Privacy Practices. Your request must state the specific restriction requested
and to whom you want the restriction to apply.
The practice is not required to agree to a restriction that you may request. We
will notify you if we deny your request to a restriction. If the practice does
agree to the requested restriction, we may not use or disclose your protected
health information in violation of that restriction unless it is needed to provide
emergency treatment. Under certain circumstances, we may terminate our
agreement to a restriction. You may request a restriction by contacting the
• Right to Request Confidential Communications. You have the right to
request that we communicate with you about medical matters in a certain way
or at a certain location. For example, you can ask that we only contact you at
work. However, you must provide us with an address to which we can send all
written correspondence, including your bill.
You may request a change to your confidential communications address and
phone number by submitting a written request to the Privacy Officer. We will
not ask you the reason for your request. We will accommodate reasonable
requests. Your request must specify how or where you wish to be contacted.
• Right to a Paper Copy of This Notice. You have the right to a paper copy
of this notice. You may ask us to give you a copy of this notice at any time.
CHANGES TO THIS NOTICE
• We reserve the right to change this notice. We reserve the right to make the
revised or changed notice effective for protected health information we already
have about you as well as any information we receive in the future. We will
post a copy of the current notice in the practice. The notice will contain on the
first page, in the upper right-hand section, the effective date.
If you believe your privacy rights have been violated, you may file a complaint with
this medical practice or with the Secretary of the Department of Health and Human
Services. To file a privacy complaint with this medical practice, contact the Privacy
Officer at 901-747-0040 or submit it in writing to 55 Humphreys Center Drive Suite
200 Memphis, TN 38120 Attn: Privacy Officer.
You will not be penalized for filing a complaint.
OTHER USES OF PROTECTED HEALTH INFORMATION.
Other uses and disclosures of protected health information not covered by this
notice or the laws that apply to us will be made only with your written
authorization. If you provide us authorization to use or disclose protected health
information about you, you may revoke that authorization, in writing, at any time.
If you revoke your authorization, we will no longer use or disclose protected health
information about you for the reasons covered by your written authorization. You
understand that we are unable to take back any disclosures we have already made
with your authorization, and that we are required to retain our records of the care
that we provided to you.