This Notice of Privacy Practices applies to the medical practice of Gautam Samadder, M.D., Rajib Saha, D.O., M.S., Maninder Kalra, M.D., and the services provided by Gautam Samadder, M.D., Inc. (doing business as Columbus Sleep Consultants, Inc.) and their current, past, and future affiliates, including Eastside Sleep Diagnostic Center, Grove City Sleep Diagnostic Center, Knightsbridge Sleep Diagnostic Center, Newark Sleep Diagnostic Center, Lancaster Sleep Diagnostic Center, any physician or physician's assistant-certified practicing herein.
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.
We¹ consider your personal information to be confidential. We are required by law to protect the privacy of that information in accordance with federal and state privacy laws, as well as our own company privacy policies. We are required by law to provide you with this Notice of Privacy Practices in which we describe our legal duties and privacy practices with respect to your personal information.
This notice describes how we may use and disclose information about you in providing health care services, and it explains your legal rights regarding the information.
When we use the term "personal information", we mean financial, health and other information about you that is nonpublic, and that we obtain so we can provide you with health care services. By "health information", we mean information that identifies you and relates to your medical history (i.e., the health care you receive or the amounts paid for that care.)
This notice will become effective on April 14, 2003.
How We Use and Disclose Personal Information
In order to provide you with health care services, we need personal information about you, and we obtain that information from many different sources – particularly your Patient Registration Form (and other paperwork you fill out when you visit us), your insurer(s), HMOs or third-party administrators (TPAs), and your other health care providers. In the course of providing health care services, we may use and disclose personal information about you in various ways, including:
Health Care Operations: We may use and disclose information during the course of running our medical practice and sleep diagnostic and consulting services – that is, during operational activities such as quality assessment and improvement; health services research and preventative health, disease management, case management and care coordination. For example, we may use the information to provide sleep programs for patients with specific conditions, such as insomnia, snoring, sleep apnea and narcolepsy. Other operational activities requiring use and disclosure include transfers of personal information between our affiliates to facilitate billing and the scheduling of appointments, and other general administrative activities, including data and information systems management.
Payment: To help pay for your health care services, we may use and disclose personal information in a number of ways – in submission of claims for insurance and in answering insurers' questions for determining eligibility. For example, we may submit your medical history and other health information about you to your insurer to allow it to determine whether treatment is medically necessary and what the payment should be. We may then discuss your medical history with your insurer to assist in the payment of your account by your insurer – we would answer specific questions about your diagnosis, medical history, and other health information to allow your insurer to determine coverage.
Treatment: We may disclose information to other doctors, dentists, pharmacies, hospitals and other health care providers who take care of you. For example, we may disclose all or a portion of your medical history to a pharmacy when we prescribe medication for you. We may provide all or a portion of your medical history to another doctor with whom we are consulting in your medical care. Other doctors involved in your care may request medical information from us to supplement their
records.
Appointment Reminders: We may contact you at the locations you specify in your Patient Registration Form or otherwise provide to us to provide appointment reminders. We will limit oral messages at these locations to the date and time of the appointment and other information you may need to identify that the messages are from us (such as the sleep diagnostic center name and contact information). We will not disclose additional health information in these messages.
Disclosures to Other Covered Entities: We may disclose personal information to other covered entities, or business associates of those entities for treatment, payment and certain health care operations purposes. For example, we may disclose personal information to other health plans maintained by your employer if it has
been arranged for us to do so in order to have certain expenses reimbursed.
Additional Reasons for Disclosure
We may use or disclose health information about you in providing you with treatment alternatives, treatment reminders, or other health-related benefits and services.
We also may disclose such information in support of:
- Plan Administration – to your employer, when we have been informed that appropriate language has been included in your health plan documents.
- Research – to researchers, provided measures are taken to protect your privacy.
- Business Associates – to persons who provide services to us and assure us they will protect the information.
- Industry Regulation – to state insurance departments, boards of pharmacy, U.S. Food and Drug Administration, U.S. Department of Labor and other government agencies that regulate us.
- Law Enforcement – to federal, state and local law enforcement officials.
- Legal Proceedings – in response to a court order or other lawful process.
- Public Welfare – to address matters of public interest as required or permitted by law (e.g., child abuse and neglect, threats to public health and safety, and national security).
Disclosure to Others Involved in Your Health Care
We may disclose health information about you to a relative, a friend, the subscriber of your health benefits plan, or any other person you identify on your Patient Registration Form, provided the information is directly relevant to that person's involvement with your health care or payment for that care. For example, if a family member or a caregiver specifically listed and authorized on your Patient Registration Form calls us with prior knowledge of your medical history, we may discuss aspects of your personal information. You have the right to stop or limit this kind of disclosure by providing written notice to us.
Uses and Disclosures Requiring Your Written Authorization
In all situations other than those described above, we will ask you for your written authorization before using or disclosing personal information about you. If you have given us authorization, you may revoke it at any time, if we have not already acted on it. If you have questions regarding authorization, please contact our Practice Administrator/Privacy Officer.
¹For the purpose of this notice, "Columbus Sleep Consultants" and the pronouns "we", "us" and "our" refer to the medical practice of Gautam Samadder, M.D., Rajib Saha, D.O., M.S., Maninder Kalra, M.D., and the services provided by Gautam Samadder, M.D., Inc. (doing business as Columbus Sleep Consultants, Inc.) and their current, past, and future affiliates, including Eastside Sleep Diagnostic Center, Grove City Sleep Diagnostic Center, Knightsbridge Sleep Diagnostic Center, Newark Sleep Diagnostic Center, Lancaster Sleep Diagnostic Center, any physician, physician assistant-certified practicing herein. These entities have been designated as a single affiliated covered entity for federal privacy purposes.
Patient Signature_______________________________________________Date_____________