Notice of Privacy Practices
Effective April 14, 2003
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.
I hereby authorize the use or disclosure of medical information about me as described below:
(1) Twin Rivers Medical Laboratory, Inc is authorized to make use or disclosure of my medical information to:
(a) Treating physicians
(b) Hospitals
(c) Clinics
(d) Insurance companies
(2) Both we and other health care providers may use the medical information to provide, coordinate, or manage your health care and related services. We may disclose medical information about you to doctors, nurses, hospitals, and other health facilities that may become involved in your health care.
(3) We may use and disclose medical information about you so that we may be paid for the services we provide to you. This can include billing you, your insurance company, Medicare, Medicaid, or a third party payor.
(4) We may use and disclose medical information about you for our own health care operations. For example, we may use medical information to review the services we provide and the performance of our employee’s phlebotomy skills.
(5) Unless you tell us otherwise in writing, we may contact you by telephone, fax, or mail at either your home or office. We may leave messages on the answering machine or voice mail.
(6) We may disclose to a family member, other relative, a close personal friend, or any other person identified by you, medical information directly relevant to that person’s involvement with your care or payment related to your care. If there is a family member or personal friend that you do not want us to disclose medical information about you to, please notify any of our staff.
(7) We may use or disclose medical information about you when we are required to do so by law.
(8) We may disclose medical information about you for public health services and purposes. This includes reporting medical information to a public health authority that is authorized by law to collect or receive the information for purposes of preventing or controlling disease. Or, one that is authorized to receive reports of child abuse and neglect.
(9) We may disclose medical information about you in the course of any judicial or administrative proceedings in response to an order of the court. We may also disclose medical information about you in response to a subpoena, discovery request, or other legal process but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed.
(10) We may use or disclose medical information about you to avert serious threat to health and safety of a person or the general public.
(11) If you are a member or retired member of the Armed Forces, we may use and disclose medical information about you deemed necessary to assure proper execution of the military mission. We may release medical information to the Veteran’s Administration if you so designate.
(12) We may disclose medical information about you to a correctional institution or law enforcement official having custody of you to provide health care to you, for the health and safety of others, or the safety and good order of the correctional institution.
(13) We may disclose medical information about you to the extent necessary to comply with workers’ compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.
(14) Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any time by notifying Twin Rivers Lab in writing of your desire to revoke it.
(15) You have the right to request that we restrict the uses or disclosures of medical information about you. You may do so at the time you complete your consent form or at any time after that time. If you request a restriction after that time, you must do so in writing to Twin Rivers Lab and tell us: what information to restrict and to whom you want the limits to apply.
(16) You have the right to inspect and obtain a copy of medical information about you. This must be requested in writing.
(17) You have the right to receive an accounting of disclosures of medical information about you.
(a) Certain disclosures are not included in such an accounting:
(1) Disclosures to receive payment
(2) Disclosures for national security
(3) Disclosures to correctional institutions or law enforcement officials
(4) Disclosures made prior to April 14, 2003
(b) Request for accounting of disclosures must be submitted in writing and state the time period requested. We will try to act on the request within 60 days.
(18) You have a right to obtain a copy of our Notice of Privacy Practices. You may obtain a paper copy or over the Internet at our web site, www.trmlab.com.
(19) We are required by law to maintain the privacy of medical information about you and to provide individuals with notice of our legal duties and privacy practices with respect to medical information. We are required to abide by the terms of our Notice of Privacy Practices in effect at the time [45 CFR {164.520(b)(v)(B)
(20) We reserve the right to change this Notice of Privacy Practices.
(21) A copy of our current Notice of Privacy Practices will be posted on the wall of the drawing station and on our web site www.trmlab.com. At any time you may obtain a copy of our current Notice of Privacy Practices by contacting Carolyn Butler 902 W Broadway, Logansport In telephone (574) 739-0004
(22) The effective date of the notice is stated on the first page of the notice.
(23) You may complain to us and to the United States Secretary of Health and Human Services, send your complaint to him or her in care of: Office for Civil Rights, U>S> Department of Health and Human Services, 200 Independence Avenue SW, Washington, D>C> 20201
You will not be retaliated against for filing a complaint.
If you have any questions or want more information concerning this Notice of Privacy Practices, please contact Connie Bostic 902 W Broadway, Logansport, In 46947
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