NOTICE OF PRIVACY PRACTICES
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Cardiovascular Associates ofNorth Central Arkansas, P.A.
555 West 6th Street
Mountain Home, AR 72653
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS CAREFULLY.
Our Privacy Commitment
Thank you for giving us the opportunity to serve you. In the normal course of business - providing medical care to you Cardiovascular
Associates of North Central Arkansas, PA creates records about you and the treatment and services we provide
to you. The information we collect is called Protected Health Information (PHI). We take our obligation to keep your PHI secure
and confidential very seriously.
We are required by federal and state law to protect the privacy of your PHI in your healthcare records and any other identifiable
patient health information used or disclosed by us in any form and provide you with this Notice about how we safeguard and use
it. We are also required by law to notify you following a breach of your unsecured PHI.
When our office, its employees, Business Associates and other involved parties use or disclose your PHI, we are bound by the
terms of this Notice that is currently in effect. This Notice applies to all electronic or paper records we create, obtain and/or
maintain that contain your PHI, including clinical notes, lab results, x-rays and medication history.
After reading this Notice, we will need your signature on a written, dated Consent or Acknowledgement Form before we will use
ordisclose your PHI for certain purposes. You may request and receive a copy of this Notice. You may take back or revoke
your consent or authorization at any time (unless we have already acted based on it) by submitting to us in writing a revocation.
Your revocation will take effect when we receive it. It will not affect what we have already used or disclosed in our reliance on
If you do not sign our Authorization/Acknowledgement Form or if you revoke it in the future, your PHI may be used or disclosed
as permitted or required by law.
This Notice of Privacy Practices is NOT an authorization.
How We Protect Your Privacy
We restrict access to your PHI to authorized workforce members (employees, volunteers, trainees and business associates) who
need that information for your treatment, for payment purposes, and/or for health care operations. We maintain technical,
physical and administrative safeguards to ensure the privacy of your PHI.
To protect your privacy, only authorized and trained workforce members are given access to our paper and electronic records
and to non-public areas where this information is stored. Our workforce members are trained on HIPAA and the privacy and
data protection required for PHI as well as maintaining technical, physical and administrative safeguards in place to maintain the
privacy and security of your PHI. Should you have any questions, please ask to speak to our business manager and privacy
offficer, Jerry Martin.
How We Use and Disclose Your PHI
Uses/disclosures of your PHI without your authorization
- To coordinate your healthcare and services with a different healthcare facility or professional.
- To share with nurses, doctors, pharmacies, health educators and other health care professionals so they can
determine a plan of care.
- To consult with your family or others so they may assist you with home care.
- Arrange appointments with other healthcare providers; schedule lab work, etc.
- To verify insurance coverage and/or receive authorization for a procedure.
- To submit claims to your health plan or third party for payment.
- To bill or collect payment from you.
- You may restrict disclosure to your insurance carrier for services if you pay "out of pocket" in full for the
- To coordinate benefits with other coverage you may have.
Disclosure to Other Individuals in Your Health Care:
- To provide customer service such as appointment reminders, calling you by name in the waiting room,
placing your name on a sign-in sheet, recommending or informing you of health-related products and
complementary or alternative treatments that may interest you. If you prefer we not contact you with
appointment reminders or information about treatment alternatives or health-related products and services,
you may notify us of this in writing and we will not use or disclose your PHI for these purposes.
- To support and/or improve the programs or services we offer you.
Special situations when your PHI will be disclosed/used without your authorization:
- To family members but only if you are present and verbally give permission.
- If you are in an emergency situation and are not present or are incapacitated, we will use our professional
judgment and the surrounding circumstances to decide whether disclosing your PHI to others is in your best
interest. If we do disclose your PHI in a situation where you are unavailable, we will only disclose information
that is directly relevant to your treatment or for payment related to your treatment. We may also disclose
your PHI in order to notify or assist in notifying such persons of your locations, your general medical
condition, or your death.
- We may disclose your child's PHI to your child's other parent.
- If you do not want us to disclose your PHI or your child's PHI to others, please let us know.
- You may name another individual to act as your personal representative. Your representative will be allowed
access to your PHI, to communicate with the health care professionals and facilities providing your care and
to exercise all other HIPAA rights on your behalf. Depending on the authority you grant your representative,
this person may also have authority to make health care decisions for you.
Uses of PHI that Require Your Authorization
- As Required by Law
- E.g., child and elder abuse, domestic violence
- To Avert a Serious Threat to Health or Safety of the Public or another Person.
- Business Associates
- We may disclose PHI to our business associates that perform functions on our behalf or provide us
with services if the information is necessary for such functions or services.
- Organ and Tissue Donation
- If you are an organ donor, we may use or disclose PHI to organizations that handle organ
- Military and Veterans
- If you are a member of the armed forces, we may disclose PHI as required by military command
- Worker's Compensation
- We may disclose PHI for workers' compensation or similar programs.
- Federal or State Government health-care oversight activities
- ie., civil rights laws, fraud and abuse investigations, audits, investigations, etc.
- Lawsuits and Disputes
- If you are involved in a lawsuit or dispute, we may disclose PHI in response to a court order or
administrative order, subpoena, discovery request or other lawful process. We will make every
effort to tell you of the request.
- Law Enforcement
- In response to a court order, subpoena, warrant, summons or similar process;
- Limited information to identify or locate a suspect, fugitive, material witness or missing person;
- About the victim of a crime even if, under certain very limited circumstances, we are unable to
obtain the person's agreement;
- About a death we believe may be in the result of criminal conduct;
- About criminal conduct on our premises; and
- In an emergency to report a crime, the location of the crime or victims, or the identity, description or
location of the person who committed the crime.
- Correctional Institution
- If you are or become an inmate of a correctional institution, we may disclose PHI to the instittution
or its agents when necessary for your health or the health and safety of others.
- National Security and Intelligence Activities
- We may release PHI about you to authorized federal officials for intelligence, counterintelligence
and other national security activities authorized by law.
- Coroners, Medical Examiners and Funeral Directors
- This may be necessary, for example, to identify a deceased person or determine the cause of
- We also may release PHI to funeral directors as necessary for their duties,
- For Research
- Those projects approved by a review board to ensure confidentiality; you will be asked to sign an
Other uses and disclosures as set forth below will be made only with your consent, authorization or opportunity to object unless
required by law. The following categories of information that are marked with an * are considered sensitive and require
enhanced privacy protection:
Your Individual Rights
- Psychotherapy notes*
- Alcohol and drug abuse prevention, treatment and referral notes*
- HIV/AIDS testing, diagnosis or treatment*
- Any PHI that contains genetic information that will be used for underwriting purposes*
- PHI that isused for marketing purposes
- Disclosures that constitute a sale of your PHI
You have the following rights regarding the PHI that we create, obtain, and/or maintain for you.
Your request must state in what form you want the list (paper or electronically) and the time period you want us to
cover. If you request an accounting more than once during any 12 month period, we will charge you a reasonable fee
for each accounting report after the first one.
- Obtain a paper copy of the Notice upon request. At your request, we will provide you with a copy of this Notice. We
are required to follow the terms of this Notice currently in effect but reserve the right to change the terms of our Notice
at any time.
- To inspect and copy your PHI. You may request in writing to review or receive a copy of your PHI that is included in
certain paper or electronic records we maintain. Under limited circumstances, we may deny you access to a portion of
your records. All original records will remain on the premises and will only be available for inspection during regular
business hours. You will have the right to request a copy in electronic format if your health record is maintained
electronically. If your PHI is maintained in electronic format but is not readily producible in such format,we will produce
it in a readable electronic format upon which we agree. We have the right to charge a reasonable fee for paper or
- Right to request restrictions. You may ask to restrict the way we use and disclose your PHI for treatment, payment,
and health care operations as explained in this Notice. We are not required to agree to the restrictions. If we agree to
the restrictions, we will follow them except in an emergency where we will not have time to check for limitations, in
which case we will ask the receiving person not to further use or disclose your PHI. We will honor your request to
restrict information to your health plan or insurer about a visit, service or prescription for which you have paid in full
provided that disclosure is not otherwise required by law. You may exercise this right at the time of service. If you do
so, no claim or communication with your health plan or insurer will occur.
- Right to receive notice of a breach. You have the right to be notified upon abreach of any of your unsecured PHI.
- Right to amend your records. You may ask us to correct or amend your PHI contained in our electronic or paper
records if you believe it is inaccurate or something is missing. We will act on your request within 30 days from receipt
of a written request. If we determine the information is inaccurate, we will notify you inwriting and make the changes
by noting (not deleting) what is incorrect or incomplete and adding the changed language. We may deny your request
under certain circumstances. If we deny your request, we will notify you in writing and you may file a complaint with us
if you disagree. If you are not satisfied with our decision, you may complain to the U.S. Department of Health and
Human Services. If a different health care facility or professional created the information that you want changed, you
should ask them to amend the information.
- Right to receive confidential communications. You may ask us in writing to communicate with you in a different way or
at a different place. We will accommodate all reasonable requests whenever feasible.
- Right to receive an accounting of disclosures. Upon your written request, we will provide a list of the disclosures we
have made of your PHI for a specified period of time. However, the list will exclude:
- Disclosures you have authorized.
- Disclosures made earlier than six (6) years before the date of your request or three (3) years in the case of
disclosures made from an electronic health record.
- Disclosures made for treatment, payment and health care operations purposes.
- Disclosures as excepted by law.
- Disclosures to you or to your personal representative.
- Disclosures incidental to a use or disclosure that is otherwise permitted or required by law.
Actions You May Take
Contact us. If you have any questions about your privacy rights, believe that we may have violated your privacy rights
or disagree with a decision that we made about access to yourPHI, you may contact us at the following address or
|Our Privacy Officer:
||Cardiovascular Associates ofNorth Central Arkansas,
||555 West 6th Street, Mountain Home, AR
||870-425-8288 Ext. 245
Contact agovernment agency. If you believe we may have violated your privacy rights, you may also file a written
complaint with the Secretary of the U.S. Department of Health and Human Services (HHS). Your complaint can be
sent by email, fax or mail to the HHS' Office for Civil Rights (OCR). You will not be retaliated against for filing a
complaint. For more information, go to the OCR website www.hhs.gov/ocr/privacy/hipaa/complaints. Mailed
complaints may be directed to:
Office ofCivil Rights
U.S. Department of Health and Human Services
1301 Young Street. Suite 1169
Dallas. Texas 75202
NOTICE AVAILABILITY AND DURATION
Notice Availability. A copy of this Notice is available from our office(s) and is posted in prominent locations in our
office at all times.
Right to change terms of this Notice. We may change the terms of this Notice at any time, and we may, at our
discretion, make the new terms effective for all of your PHI in our possession, including any PHI we created or received
before we issued the new Notice.
If we change this Notice, we will give you the new Notice when you receive treatment. In addition, we will post any
new Notice in a prominent location in our office(s).
Effective Date. These privacy practices are ineffect as of September 20, 2013, and
will remain in effect until we revise them as permitted or required by law.
is a division of the Council for Certification in Cardiovascular Imaging (CCCVI). CBNC was established in 1996 to develop and administer practice-related examinations in the field of Nuclear Cardiology. To date, 9,109 physicians have been certified in nuclear cardiology.
For further information contact:
Helen Gootinag, Certification Operations Manager
Certification Board of Nuclear Cardiology
101 Lakeforest Boulevard, Suite 401
Gaithersburg Maryland 20877 USA