Southern Pain Specialists

Notice of Information Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ CAREFULLY.

Introduction:
As part of your health care, Southern Pain Specialists originates and maintains numerous medical, billing, and other related records which contain information identifying you and describing your health history, symptoms, test results, diagnosis, treatment and any plans for future care. This notice describes how this information may be used and disclosed by Southern Pain Specialists, as well as your rights and Southern Pain Specialist's duties with respect to such information.

Your Health Information Rights:
Although all records relating to the treatment you receive at Southern Pain Specialists are the property of Southern Pain Specialists, you have the following rights with respect to your health information:

The right to request restrictions on certain uses and disclosures of your health information as provided by 45 C.F.R. 164.522. Southern Pain Specialists is not required to agree to any requested restriction.
The right to obtain a copy of this Notice upon request.
The right to inspect and obtain a copy of your health information as provided in 45 C.F.R. 164.524.
The right to amend your health information as provided in 45 C.F.R. 164.526.
The right to obtain an accounting of disclosures of your health information as provided in 45 C.F.R. 164.528.
The right to receive confidential communications of your health information as provided in 45 C.F.R. 164.522(b), as applicable.
The right to revoke your authorization to use or disclose health information except to the extent that action has already been taken.

You may exercise any of these rights by contacting the Southern Pain Specialists representative listed below.

Facility Responsibilities:

Southern Pain Specialists is required by law to:

Maintain the privacy of your health information and to provide you with a notice as to Southern Pain Specialists' legal duties and privacy practices with respect to your health information.
Abide by the terms of this Notice, as it may be revised from time to time.

     Southern Pain Specialists reserves the right to change the terms of this Notice and to make any revisions to the Notice effective for all your health information that Southern Pain Specialists maintains.

     Should Southern Pain Specialists change the terms of this Notice it will mail a revised notice to the address you have supplied us as well as post the revised notice in an area accessible to all patients.

     We will not use or disclose your health information without your authorization, except as described in this notice.

For More Information or to Report a Problem:
     If you have questions or would like additional information, you may contact:

Robin Mosher at 995-9967 ext. 203

     If you believe your privacy rights have been violated, you can file a complaint with the same person, or with the Secretary of the Department of Health and Human Services without fear of retaliation for filing a complaint. All complaints must be in writing.

Use and Disclosure of Your Health Information:

     Southern Pain Specialists is permitted to use or disclose your health information in the following ways:

     Treatment: Southern Pain Specialists is permitted to use or disclose your health information on the provision and coordination of your healthcare. We may disclose all or any portion of your health information to your attending physician, consulting physician(s), nurses, technicians, and other health care providers who have a legitimate need for such information in your care and continued treatment. Southern Pain Specialists may share information about you with other providers in order to coordinate specific services, such as prescriptions, lab work and x-rays. Southern Pain Specialists also may disclose your health information to people outside the office who may be involved in your medical care after you leave the office, such as family members, clergy, and others used to provide services that are part of your care.

     Family/Friends: Southern Pain Specialists may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are being treated at Southern Pain Specialists.

     Payment: Southern Pain Specialists may release health information about you for the purposes of determining coverage, billing, claims management, medical data processing, and reimbursement. Your health information may be released to an insurance company, third party payer or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record that are necessary for payment of your account. For example, a bill sent to a third party payer may include information that identifies you, your diagnosis, and the services and supplies provided to you.

Effective Date: April 14, 2003