Privacy Practices
For an electronic copy of this notice, click HERE.
Elkhart Clinic, LLC Notice of Privacy Practices
Effective Date: April 14, 2003
Revised Date: 9/24/19
Please review this notice carefully. This notice describes how medical information about you may be used and disclosed. It also describes how you can get access to this information. If you have any questions about this Notice of Privacy Practices, please contact our Privacy Officer at Elkhart Clinic, 303 South Nappanee St., Elkhart, IN 46514, or call 574-296-3200.
Our Pledge Regarding Medical Information
We understand that health information about you and your health care is personal. We are committed to protecting your health information. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. We are require by law to:
Make sure that medical information that identifies you is kept private
Give you notice of our legal duties and privacy practices with respect to medical information about you
Follow the terms of the notice that is currently in effect
Notify you if there is a breach of your medical information
How We May Use and Disclose Your Medical Information
The following describe the different ways that we use and disclose medical information. For each section of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosures in a section will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the sections. In certain circumstances we may use and disclose your medical information without your written consent.
For Treatment: We may use medical information about you to provide you with medical treatment or services without your written consent. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are taking care of you. Some examples are:
Your physician or a staff member may need to talk to another physician who will provide your care when he or she is away
Your physician or a staff member may want to refer you to a specialist and will discuss your condition with that specialist
Your physician or a staff member may want you to see a nutritionist and may talk to that nutritionist about your dietary needs
Your physician or a staff member may want to talk with family or clergy members who will assist you with care you need outside the office
For Payment: We may use and disclose your medical information so that the treatment and services you receive from Elkhart Clinic may be billed to and collected from you, an insurance company, or a third party without your written consent. We may tell an insurance company or a third party about care you are going to receive in order to obtain prior approval or determine your coverage.
For Health Care Operations: In order to run our practice in a way that ensures that our patients receive quality care, we may use and disclose medical information without your written consent. The following are examples of disclosures of medical information for health care operations. We may:
Use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you
Combine your medical information with medical information about other patients to determine if we need to offer additional services to patients
Disclose medical information to doctors, nurses, technicians and medical students for review and learning purposes
Combine the medical information we have with medical information from other practices to see where we can make improvements in our care and services
Release de-identified health information so that others can use it to study health care without learning who the specific patients are.
Business Associates: We may use or disclose your medical information to an outside company that assists us in operating our health system. They perform various services for us. This includes, but is not limited to, auditing, accreditation, legal services, and consulting services. These outside companies are called ‘business associates’ and they contract with us to keep any medical information received from us confidential in the same way we do. These companies may create, receive, transmit, or maintain medical information on our behalf.
Family Members and Friends: If you agree, do not object to, or Elkhart Clinic reasonably infers that there is no objection, we may disclose medical information about you to a family member, relative, or another person identified by you who is involved in your health care or payment for your health care. If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing limited medical information is in your best interest under the circumstances. We may disclose medical information to a family member, relative, or another person who was involved in the health care or payment for health care of a deceased individual if not inconsistent with the prior expressed preferences of the individual that are known to Elkhart Clinic. You have the right to request a restriction on our disclosure of your medical information to someone who is involved in your care.
Appointment Reminders: We may use and disclose medical information to contact you to remind you that you have an appointment for treatment or services. If you do not want us to contact you for appointment reminders, you must notify us.
Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Disclosures to You: Upon written request by you, we may use or disclose your medical information in accordance with your request.
Disclosures to the Secretary of Health and Human Services: We might be required by law to disclose your medical information to the Secretary of the Department of Health and Human Services, or his/her designee, in the case of a compliance review to determine whether we are complying with privacy laws.
Disclosures of Records Containing Drug or Alcohol Abuse Information: Because of federal law, we will not release your medical information if it contains information about drug or alcohol abuse without your written permission except in very limited situations.
Disclosures of Mental Health Records: If your records contain information regarding your mental health, we are restricted in the ways we may use or disclose them. We can disclose such records without written permission only in the following situations:
If the disclosure is made to you (unless it is determined by a physician that the release would be detrimental to your health)
Disclosures to our employees in certain circumstances
For payment purposes
For data collection, research, and monitoring managed care providers if the disclosures is made to the division of mental health
For law enforcement purposes or to avert a serious threat to the health and safety of you or others
To a coroner or medical examiner
To satisfy reporting requirements
To satisfy release of information requirements that are required by law
To another provider in an emergency
For legitimate business purposes
Under a court order
To the Secret Service if necessary to protect a person under Secret Service protection
To the Statewide waiver ombudsman
National Security and Intelligence Activities: We may release your medical information to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities authorized by law.
Research: Under certain circumstances we may use and disclose medical information about you for research purposes. Occasionally, we might disclose medical information to researchers preparing to conduct a research project. For example, we may assist researchers in looking for patients with specific medical needs.
There are several things you should know about research projects:
Research projects are subject to a special approval process, usually handled by the Food and Drug Administration (FDA). The approval process includes considering a patient’s right to privacy of their health information and the need to conduct research to improve medical care. Before one of your physicians would participate in a research project, the FDA will have approved it;
If you are a candidate for participation in a research project, you will always be given very specific information about the research project and be asked if you want to participate.
If it is necessary to disclose your name or address or other personal health information that specifically reveals who you are, we will request permission from you.
Shared Medical Records/Health Information Exchanges (HIEs): We maintain medical information about our patients in electronic medical records that allow the Elkhart Clinic associates to share medical information. We may also participate in various electronic HIEs that facilitate access to medical information by other health care providers who provide you care.
As Required by Law: We will disclose medical information about you when we are required to do so by federal, state or local law. For example, we are required to report suspected child or elder abuse, sexually transmitted diseases, HIV, or tuberculosis, etc.
To Avert A Serious Threat To Health Or Safety: We may use and disclose medical information about you when it is necessary to prevent a serious threat to your health and safety, or the health and safety of the public or of another person. Disclosure will be made to someone who is able to help prevent the threat.
Special Situations:
Military or Veterans: If you are a member of the armed forces, we may disclose medical information about you as required by military command authorities. We may disclose medical information about foreign military personnel to the appropriate foreign military authority.
Worker’s Compensation: We may disclose medical information about you for worker’s compensation or similar programs.
Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following:
To prevent or control disease, injury, or disability.
To report births or deaths.
To report reactions to medications or problems with medical 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 contacting 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 by law.
Health Oversight Activities: We may disclose medical 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 laws.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement: We may release medical 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.
About the victim of a crime if, under certain circumstances, we are unable to obtain the victim/patient’s agreement.
About a death we believe may be the result of criminal conduct.
About criminal conduct in the practice’s office.
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 the crime.
Coroners, Medical Examiners, and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary for example, to identify a deceased person or to determine the causes of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release 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 and safety of others, or 3) for the safety and security of the correctional institution.
Other Uses of Medical Information: Other uses and disclosure of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosure we have already made with your permission and that we are required to retain our records of the care that we provided you.
Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy:
You have the right to inspect and copy your medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but excludes psychotherapy notes.
To inspect and copy your medical information, you must submit your request in writing to the Manager of Health Information by filling out an Authorization For Release of Information Form. This can be done in person at the information desk or by requesting the form be mailed or faxed by calling (574) 296-3200. 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.
Your physician may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request the denial be reviewed. Another licensed health care professional will review your request and denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend:
If you feel that medical 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 this practice.
To request an amendment, your request must be made on our Request for Amendment of Health Information form and submitted to the Manager of Health Information. This can be done in person at the information desk or you may request a form be mailed to you by calling the Manager of Health Information at (574) 296-3200. Your request should include the 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. In addition, we may deny your request if you ask us to amend information that:
Was not created by Elkhart Clinic, unless the person or entity that created the information is no longer available to make the amendment
Is not part of the medical information kept by or for Elkhart Clinic
Is not part of the information which you would be permitted to inspect and copy
Is accurate and complete
Right to Accounting of Disclosures:
You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical information about you.
To request this list or accounting of certain disclosures, you must submit your request in writing to the Manager of Health Information by filling out the Accounting for Disclosures of Health Information This can be done in person at the information desk or by requesting the form be mailed to you by calling the Manager of Health Information at (574) 296-3200. Your request must state a time period, which may not be longer than six years, and may not include dates before April 14, 2003. Your request should state the desired format you want the list (for example, on paper or electronic)
The first list you request within a 12-month period will be free of charge. 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 the time before any costs are incurred.
Right to Request Restrictions:
You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
To request restrictions, you must submit your request in writing to the Manager of Health Information by filling out the Request to Restrict Health Information This can be done in person at the information desk or by requesting the form be mailed to you by calling the Manager of Health Information at (574) 296-3200. In your request, you must tell us a) what information you want to limit, b) whether you want to limit our use, disclosure, or both, and c) to whom you want the limits to apply, for example, disclosures to your spouse.
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 or only by mail.
To request confidential communications, you must submit your request in writing to the Manager of Health Information by filling out the Request for Confidential Handling of Health Information This can be done in person at the information desk or by requesting the form be mailed to you by calling the Manager of Health Information at (574) 296-3200. We will not ask you the reason for your request. We will accommodate all reasonable requests.
Right To 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. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice at our website, elkhartclinic.com
To obtain a paper copy of this notice, call the Elkhart Clinic Privacy Officer at (574) 296-3200 and one will be mailed to you.
We will request that you sign a separate form acknowledging you have been offered a copy of this notice. If you choose, or are not able to sign, a staff member will sign their name and date. This acknowledgement will be filed with your records.
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 medical 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 waiting room
Complaints: If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the practice, you will need to fill out a Privacy Complaint Form. This can be done in person at the information desk or requested to be mailed to you by calling the Privacy Officer at (574) 296-3200. The completed form should be mailed to:
Elkhart Clinic
303 S. Nappanee
Elkhart, IN 46514
Attn: Privacy Officer
All complaints should be submitted in writing. You will not be penalized, discriminated against, retaliated against, or intimidated for filing a complaint.