Respiratory Questionaire 1
This OSHA compliant form is required as part of a respirator fit test. It is also required as part of a formal HAZWOPER exam. Please read and complete the questionaire carefully.
Notice of Privacy Practices
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.
This Notice of Privacy Practices describes how Fairweather may use and disclose your protected health information to carry out treatment, payment or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including personal statistics, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
1. Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, office staff and others outside of my office who are involved in your care for the purpose of providing health care services to you. Your protected health information may also be used to pay your health care bills and to support the operation of this practice. Following are examples of disclosure that Fairweather is permitted to make.
Treatment - Includes information to provide, coordinate, or manage your health care and related services. For example, Fairweather may release information to another physician to whom you may have been referred for assistance to diagnose or treat you. Another example would be to disclose information to a home health agency that provides care to you.
Payment - Includes information, as needed, to obtain payment for your health care services. This may include release of information for certain activities that your health care plan requires to approve or pay for services, such as: to determine eligibility, medical necessity or utilization review. For example, obtaining approval for a hospital stay may require Fairweather to release information to your insurance, prior to admission.
Health Care Operations- Fairweather may need to disclose, as needed, information in order to support administrative and business activities of my practice. These activities may include, but are not limited to, licensing, and quality assessment activities.
Fairweather may share your information with third party “business associates” that perform various activities for my practice, such as by billing company. Fairweather business associates have a written contract that contains terms to protect the privacy of your protected health information.
2. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization
Fairweather may disclose your protected health information in the following situations without your authorization or providing you with an opportunity to agree or object. These situations include:
Requirements by Law- for release of information to for emergency situations or to avert serious health or safety situations. Any disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified if required by law, of any such disclosure to:
- Law enforcement or judicial agencies - Health oversight regulatory agencies
- Public Health Agencies - Any other protection required by law
- Information protected beyond that required by law - Military Activity and National Security
For your medical treatment, such as:
- to remind you of appointments - tell you of treatment alternatives
- to communicate with your family - to get an interpreter for you
For other reasons to improve your health, such as:
- Organ Procurement
- Food and Drug Administration
3. Uses and Disclosures of Protected Health Information based upon your written authorization
Other uses and disclosures will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, Fairweather will no longer use or disclose your information for the reasons covered by your written authorization. Please understand that Fairweather is unable to take back any disclosures already made with your authorization.
4. Uses and disclosures that require providing you the opportunity to agree or object.
Fairweather may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use of all or part of the information. If you are not present or able to agree or object, the provider, as your physician may use professional judgment to determine whether the use is in your best interest.
Others involved in your care: Unless you object, Fairweather may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your care. Fairweather may use or disclose information to notify or assist in notifying these persons of your location, general condition or death. Finally, Fairweather may use or disclose information to an authorized public or private entity to assist in disaster relief efforts and to coordinate disclosure to individuals involved in your health care.
5. Your Rights
You have the right to inspect and copy your protected health information for as long as Fairweather maintains your protected health information. You may obtain your medical record that contains medical and billing records and any other records that my practice uses for making decisions about you. As permitted by federal or state law, Fairweather may charge you a reasonable fee for a copy of your records.
Under federal law, however, you may not inspect or copy: psychotherapy notes; information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative proceeding; laboratory results that are subject to law that prohibits access to protected health information. Depending on circumstances, a decision to deny access may be reviewed, and you may have a right to have this decision reviewed.
You have the right to have your physician amend your protected health information. You may request an amendment about you in a designated record for as long as I maintain this information. In certain cases, I may deny your request. If your request is denied, you have the right to file a statement of disagreement, for which I may prepare a rebuttal. I will provide you with a copy of any such rebuttal.
You have the right to request a restriction of your protected health information . You may ask me not to use or disclose any part of your information for the purposes of treatment, payment or health care operations. You may also request that any or part of your information not be disclosed to individuals involved in your care or for notification purposes described in this Notice of Privacy. Your request must state the specific restriction and to whom you want the restriction to apply. Fairweather does not have to grant your request if in their professional judgment, Fairweather feels that the restriction is not in your best interest. If Fairweather does agree to your request, Fairweather will not use or disclose that information unless it is needed to provide emergency treatment.
You have the right to receive confidential communications from me by alternative means or at an alternative location. Fairweather will accommodate any reasonable written request. Fairweather may condition this accommodation by asking you for information as to how payment will be handled, or for an alternative address or other method of contact. Fairweather will not request an explanation from you as to the basis of this request.
You have the right to receive an accounting of certain disclosures made, if any, of your protected health information. This right applies to disclosures for purposes other than those made for treatment, payment or health care operations, as described in this Notice of Privacy. It excludes disclosures made, if you authorized Fairweather to make disclosure to individuals involved in your care, for notification purposes, for national security or intelligence, or to law enforcement or correctional facilities. You have the right to specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions, and limitations.
You have the right to obtain a paper copy of this notice from me, upon request, even if you have agreed to accept this notice electronically.
You may make complaints to Fairweather in writing, or to the Secretary of Health and Human Services, if you feel that your privacy rights have been violated. You will not be retaliated against for filing a complaint. You may contact Fairweather at 907-267-4603.
Fairweather is required by law to maintain the privacy of your private health information and must abide by the terms of this Notice or any update of this Notice. Fairweather reserves the right to make changes to this notice and will issue revisions at your request, or at your first appointment after any revisions have been made.
This notice becomes effective October 29, 2012
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