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.
Avanta Clinic LLC is required to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices. Avanta Clinic LLC will not use or disclose your health information except as described in this notice. This notice applies to all of the medical records generated by Avanta Clinic LLC.
YOUR RIGHTS REGARDING USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION:
The following categories describe the ways that Avanta Clinic LLC may use and disclose your health information.
Treatment: Avanta Clinic LLC will use your health information in the provision and coordination of your health care. We may disclose all or any portion of your medical record information to your referring physician, consulting physician(s), nurses, and other health care providers who have a legitimate need for such information in the care and continued treatment of you, as a patient.
Family/Friends: Medical information may also be disclosed to other people involved in your medical care, such as family members, friends, clergy, and others who provide services that are part of your care. We may also give information to someone who helps pay for your care.
Treatment Alternatives: Avanta Clinic LLC may use and disclose your medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. For example, we may contact you to inform you of the release of new or improved pharmaceuticals which may aid in the treatment of your particular condition.
Payment: Avanta Clinic LLC may release medical information about you for the purposes of determining coverage, billing, claims management, medical data processing, and reimbursement. The 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, which 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 imaging procedures you had.
Routine Healthcare Operations: Avanta Clinic LLC may use and disclose your medical information during routine health care operations, including those for quality assurance, compliance programs, utilization review, medical review, internal auditing, accreditation, certification, licensing, credentialing, training, peer review, case management activities, coordination of care, referrals to other providers, legal services, and business planning.
Communications: Avanta Clinic LLC may use and disclose medical information to contact you by telephone or mail and remind you of an appointment for an examination or care, to ask you for information necessary to appropriately schedule and perform an examination, to give you information or instructions about your examination, or to give you the results of your examination. Avanta Clinic LLC may also use non-secure channels such as text message or email for communication of non-medical information.
Health-Related Business and Services: Avanta Clinic LLC may use and disclose your medical information to tell you of health-related benefits or services that may be of interest to you.
Business Associates: Avanta Clinic LLC may use and disclose certain medical information about you to its Business Associates. A Business Associate is an individual or entity under contract with Avanta Clinic LLC to perform or assist Avanta Clinic LLC in the performance of functions or activities that necessitate the use and disclosure of medical information. Examples of Business Associates include, but are not limited to, third-party billing companies, electronic health record vendors, medical transcriptionists, imaging archival companies, medical record copying services, companies hired to destroy or dispose of outdated medical records and imaging studies, lawyers, accountants, and consultants. Avanta Clinic LLC requires its Business Associate to protect the confidentiality of your medical information.
Research: Under certain circumstances, Avanta Clinic LLC may use and disclose medical information about you to researchers when the clinical research study has been approved by a review board. While most clinical research studies require specific patient consent, there are some instances where a retrospective records review with no patient contact may be conducted by such researchers. For example, the research project might involve a review of how well a particular disease was detected on various modalities.
Marketing: Avanta Clinic LLC may disclose certain contact information to a third party to provide marketing materials and information related to health care services to you. We may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly describe products or services provided by this practice and tell you which health plans this practice participate in. We may also encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease management program, provide you with gifts, tell you about government sponsored health programs or encourage you to purchase a product or service when we see you, for which we may be paid. Finally, we may receive compensation to remind you to take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you. We will not use or disclose your medical information for marketing purposes to a 3rd party or accept any payment for other marketing communications without your prior written authorization.
Sale of Health Information: Avanta Clinic LLC will not sell your health information without your prior written authorization. The authorization will disclose that we receive compensation for your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization.
Regulatory Agencies: Avanta Clinic LLC may disclose your medical information to a health oversight agency for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations, and inspections. These activities are necessary for the government and certain private health oversight agencies to monitor the health care system, government programs, and compliance with civil rights.
Law Enforcement: Avanta Clinic LLC may disclose your medical information for law enforcement purposes as required by law or in response to a valid subpoena or court order.
Public Health: As required by law, Avanta Clinic LLC may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. For example, the law requires reporting cases of tuberculosis and cases of suspected child abuse.
Workers Compensation: Avanta Clinic LLC may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Military Veterans: Avanta Clinic LLC may disclose your medical information as required by military command authorities, if you are a member of the armed forces.
Inmates: If you are an inmate of a correctional institute or under the custody of a law enforcement officer, Avanta Clinic LLC may release your medical record information to the correctional institute or law enforcement official.
Required by Law: Avanta Clinic LLC will disclose medical information about you when required to do so by law.
Coroners, Medical Examiners, Funeral Directors: Avanta Clinic LLC may release your medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine a cause of death. Avanta Clinic LLC may also release your medical information to general directors as necessary to carry out their duties.
Other Uses: Any other uses and disclosures will be made only with your written authorization.
PATIENT HEALTH INFORMATION RIGHTS:
Although all of your records and imaging data at Avanta Clinic LLC are the property of Avanta Clinic LLC, you have the following rights concerning your medical information.
Right to Confidential Communications: You have the right to receive confidential communications of your medical information by alternative means or at alternative locations. For example, you may request in writing that Avanta Clinic LLC only contact you at work or by mail.
Right to Inspect and Copy: You have the right to inspect and copy your medical information as provided by 45 CFR § 164.524. Copying fees will be charged.
Right to Amend: You have the right to request amendment of your medical information as provided by 45 CFR § 164.526. Avanta Clinic LLC requires completion of a written amendment request, including your reason for the requested amendment.
Right to an Accounting: You have the right to obtain a statement of the disclosures of your medical information made for purposes other than treatment, payment, and health care operations, as provided by 45 CFR § 164.528. The request must be in writing.
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your medical information as provided by 45 CFR § 164.522. However, Avanta Clinic LLC is not required to agree to honor your request.
Right to Receive Copy of this Notice: You have the right to receive a paper copy of this Notice, upon request.
Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your medical information except to the extent that action has already been taken in reliance on your authorization. This revocation will not apply to sharing information for the purpose of receiving payment for services already rendered to you, unless you make alternate arrangements for payment with Avanta Clinic LLC.
SPECIAL RULES REGARDING DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE, AND HIV-RELATED INFORMATION:
For disclosures concerning health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment, special restriction may apply. For example, we generally may not disclose this specially protected information in response to a subpoena, warrant or other legal process unless you sign a special Authorization or if a court orders the disclosure.
Psychiatric Information: If needed for your diagnosis or treatment in a mental health program, psychiatric information may be disclosed based upon your general Authorization, and limited information may be disclosed for payment purposes.
HIV-Related Information: HIV-related information will not be disclosed, except under limited circumstances set forth under State or Federal law, without your specific written Authorization. A general authorization for release of medical or other information will not be sufficient for purposes of releasing HIV-related information. As required by Connecticut law, if we make a lawful disclosure of HIV-related information, we will enclose a statement that notified the recipient of the information that they are prohibited from further disclosing the information.
Substance Abuse Treatment: If you are treated in a specialized substance abuse program, information which could identify you as an alcohol or drug-dependent patient will not be disclosed without your specific Authorization except for purposes of treatment, or where specifically required or allowed under State or Federal law.
FOR MORE INFORMATION OR TO REPORT A PROBLEM:
If you have questions and would like additional information, please ask one of our Avanta Clinic LLC employees or physicians. If you believe your privacy rights have been violated, you may file a complaint with Avanta Clinic LLC or with the Secretary of the Department of Health and Human Services. To file a complaint with Avanta Clinic LLC, please write to:
Sudeep Bansal, MD
Avanta Clinic LLC
131 New London Tpke, Ste 105
Glastonbury, CT 06033
You may also file a complaint with:
Office for Civil Rights
US Department of Health and Human Services
Government Center
J.F. Kennedy Federal Building – Room 1875
Boston, Massachusetts, 02203
Voice Phone: (617)565-1340
FAX: (617) 565-3809
TDD: (617) 565-1343
All complaints must be submitted in writing. There will be no retaliation for filing a complaint.
CHANGES TO THIS NOTICE:
Avanta Clinic LLC will abide by the terms of the Notice currently in effect. Avanta Clinic LLC reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains. If the Notice revision reflects a change in the subsequent potential uses and disclosures of your health information, Avanta Clinic LLC will mail any revised Notice (prior to implementation of same) to the address for you on file with Avanta Clinic LLC or such other address as you may designate in writing from time to time, unless federal regulations do not require a mailing on revision.