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 is effective as of May 2011
Notice of Privacy Practices for Protected Health Information
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 notice carefully!
The Practice of Front Range Center for Brain and Spine Surgery is
required by applicable federal and state laws to maintain the privacy
of your health information. Protected health information (PHI) is the
information we create and maintain in providing our services to you.
Such information may include documentation of your symptoms,
examination and test results, diagnoses, and treatment protocols.
It also may include billing documents for those services. We are
permitted by federal privacy law, the Health Insurance Portability
& Accountability Act of 1996 (HIPAA), to use and disclose your
PHI for the purposes of treatment, payment, and health care
operations without your written authorization.
Examples of Uses of Your Health Information
Example of a Use of Your Health Information for Treatment Purposes
Our nurse obtains treatment information about you and records it
in a health record.
During the course of your treatment, the physician determines he
will need to consult with a specialist in another area. He will share the
information with the specialist and obtain his/her input.
We may contact you by phone, at your home, if we need to speak to you
about a medical condition, or to remind you of medical appointments.
Example of a Use of Your Health Information for Payment Purposes
We submit requests for payment to your health insurance company;
the health insurance company requests information from us regarding
medical care provided to you, which we will provide to them. We may
also disclose information to our business associates who are obligated,
under contract with us, to protect the privacy of your information.
Example of a Use of Your Information for Health Care Operations
We may use or disclose your PHI in order to conduct certain business
and operational activities such as quality assessment activities, to review
employee activities, or to assist in the training of students.
Military and Veterans
If you are a member of the American armed forces or a foreign military
force, we may disclose PHI as required by the appropriate military
Lawsuits and Disputes
If you are involved in a lawsuit or dispute, we may disclose PHI
in response to a court or administrative order, subpoena, discovery
request, or other legal process. We may also use or disclose PHI to
defend ourselves in a lawsuit.
We may use or disclose your PHI to remind you about an appointment
or provide you with information about treatment alternatives
or other health-related benefits and services that may be of interest to
We may provide legally required notices of unauthorized access
to or disclosure of your health information.
Other uses and disclosure of your PHI will only be made with
your authorization, unless otherwise permitted or required by law,
as described below.
Your Health Information Rights
The health and billing records we maintain are the physical property
of the office. The information in them, however, belongs to you.
You have a right to:
- Request a restriction on certain uses and disclosures of your
health information. We are not required to grant the request,
but we will comply with any request that we agree to grant.
- Request that we contact you by mail at a specific address or call
you only at a certain phone number. You must make any such
request in writing. We will accommodate all reasonable requests
and not ask you the reason for your request for privacy.
- Obtain a paper copy of the current Notice of Privacy Practices
for Protected Health Information (“the Notice”) by making a
request at our office.
- Request that you be allowed to inspect and copy your health
record and billing record. We have up to 30 days to make
the information available to you, and may charge you a reasonable
fee for costs related to copying and mailing. We may not charge a fee
if the request is related to a claim for benefits under the Social Security
act or any other state or federal needs-based benefits program.
- Request a summary (rather than the entire record) or an explanation
of your PHI if you agree to this alternative form and pay the
- Appeal a denial of access to your protected health information,
except in certain circumstances.
- Request that your health care record be amended to correct
incomplete or incorrect information by delivering a request, in
writing, to the privacy officer listed at the end of this section.
We may deny your request if you ask us to amend information
that either was not created by us (unless the person or entity that
created the information is no longer available to make the amendment),
is not part of the health information kept by the office, is
not part of the information that you would be permitted to inspect
and copy, or is accurate and complete. If your request is denied,
you will be informed of the reason for the denial and will have an
opportunity to submit a statement of disagreement to be placed in
- Request that your health information be made available by alternative
means or at an alternative location by delivering the request
in writing to our office. We will make every effort to provide
access to your PHI in the form or format you request, or in a
standard electronic format or printed hard copy—at a reasonable
fee—if the information is not readily producible as requested.
- Restrict information going to your health plan about an item or
service for which you pay the Practice out-of-pocket and in full
for the item or service.
- Obtain an accounting of disclosures of your health information
as required to be maintained by law. An accounting will not
include uses and disclosures of information for treatment, payment,
or operations; disclosures or uses made to you or made at
your request; uses or disclosures made pursuant to an authorization
signed by you; uses or disclosures made in a facility directory
or to family members or friends relevant to that person’s involvement
in your care or in payment for such care; or, uses or disclosures
to notify family or others responsible for your care of your
location, condition, or your death.
- Your written authorization is required for most uses and disclosures
of psychotherapy notes, or uses and disclosures of PHI for
marketing purposes or the sale of your protected information.
- Revoke authorizations that you made previously to use or
disclose information by delivering a written revocation to our
office (except to the extent action has already been taken based
on a previous authorization).
If you would like to exercise any of the above rights, please contact
Nancy Timmons, Privacy Officer, in writing at 1313 Riverside Ave.,
Ft. Collins, CO, 80524, or at (970) 493-1292 during regular business
hours. The Privacy Officer will inform you of the steps needed
to exercise your rights under HIPAA.
The office is required to:
- Maintain the privacy of your health information as required by law.
- Provide you with a notice (‘Notice’) as to our duties and privacy
practices regarding the information we collect and maintain
about you, and notify you of a breach of your unsecured PHI.
- Abide by the terms of this Notice.
- Notify you if we cannot accommodate a requested restriction or
- Accommodate your reasonable requests regarding methods to
communicate health information with you and not disclose PHI
to your health plan if you request that we do not, and pay for
the item/service out-of-pocket and in full. You must request this
Patient Right in writing.
We reserve the right to amend, change, or eliminate provisions in
our privacy practices and to enact new provisions regarding the PHI
we maintain. If our information practices change, we will amend our
Notice. You are entitled to receive a revised copy of the Notice by
calling and requesting a copy, visiting our website, or by visiting our
office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or would
like to report a problem regarding the handling of your information,
you may contact the Privacy Officer. If you believe your privacy rights
have been violated, you may file a complaint by delivering it in writing
to the Practice’s Privacy Officer. You may also file a complaint with
the Secretary of Health and Human Services, Office for Civil Rights
(OCR). The address for the Colorado regional office is: Office for Civil
Rights, U.S. Department of Health and Human Services, 999-18th
Street, Suite 417, Denver, CO 80202; or call (800) 368-1019.
Information regarding the steps to file a complaint with the OCR
can also be found at: www.hhs.gov/ocr/privacy/hipaa/complaints.
We cannot, and will not, require you to waive the right to file a complaint
with the Secretary of Health and Human Services (HHS)
as a condition of receiving treatment from the office.
We cannot, and will not, retaliate against you for filing a complaint
with the Secretary of Health and Human Services.
Other Uses and Disclosures of your PHI
Communication with Family
Using our best judgment, we may disclose to a family member, other
relative, close personal friend, or any other person you identify, health
information relevant to that person’s involvement in your care or in
payment for such care if you do not object, or in an emergency. We
may also do this after your death, unless you tell us before you die
that you do not wish us to communicate with certain individuals.
Unless you object, we may use or disclose your protected health
information to notify, or assist in notifying, a family member, personal
representative, or other person responsible for your care, about your
location, and about your general condition, or your death.
We may disclose information to researchers when their research has
been approved by an institutional review board that has reviewed the
research proposal and established protocols to ensure the privacy of
your protected health information.
We may use and disclose your protected health information to assist
in disaster relief efforts.
Organ Procurement Organizations
Consistent with applicable law, we may disclose your PHI to organ
procurement organizations or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose of tissue
Food and Drug Administration (FDA)
We may disclose to the FDA your PHI relating to adverse events
with respect to food, supplements, products and product defects, or
post-marketing surveillance information to enable product recalls,
repairs, or replacements.
If you are seeking compensation through Workers Compensation,
we may disclose your PHI to the extent necessary to comply with laws
relating to Workers Compensation.
We may release health information about you to your employer if
we provide health care services to you at the request of your employer,
and the health care services are provided either to conduct an evaluation
relating to medical surveillance of the workplace or to evaluate
whether you have a work-related illness or injury. In such circumstances,
we will give you written notice of the release of information to your
employer. Any other disclosures to your employer will be made only if
you execute a specific authorization for the release of information to
As authorized by law, we may disclose your PHI to public health
or legal authorities charged with preventing or controlling disease,
injury, or disability; to report reactions to medications or problems
with products; to notify people of recalls; and to notify a person who
may have been exposed to a disease or who is at risk for contracting
or spreading a disease or condition.
Abuse & Neglect
We may disclose your PHI to public authorities as allowed by law
to report abuse or neglect.
We may disclose your PHI to law enforcement officials (a) in
response to a court order, court subpoena, warrant or similar judicial
process; (b) to identify or locate a suspect, fugitive, material witness,
or missing person; (c) if you are a victim of a crime and we are unable
to obtain your agreement; (d) about criminal conduct on our premises;
and (e) in other limited emergency circumstances in which we need to
report a crime.
Federal law allows us to release your PHI to appropriate health
oversight agencies or for health oversight activities. These oversight
activities include audits, investigations, inspections, licensure, and
similar activities that are necessary for the government to monitor the
health care system, government programs, and compliance with civil
We may disclose your protected health information in the course of
any judicial or administrative proceeding as allowed or required by
law, with your authorization, or as directed by a proper court order.
To avert a serious threat to health or safety, we may disclose your
protected health information consistent with applicable law to prevent
or lessen a serious, imminent threat to the health or safety of a person
or the public.
For Specialized Governmental Functions
We may disclose your protected health information for specialized
government functions as authorized by law such as to Armed Forces
personnel, for national security purposes, or to public assistance
If you are an inmate of a correctional institution, we may disclose to
the institution or its agents the protected health information necessary
for your health and the health and safety of other individuals.
Coroners, Medical Examiners, and Funeral Directors
We may release health information to a coroner or medical examiner.
This may be necessary, for example, to identify a deceased person
or determine the cause of death. We may also release health information
about patients to funeral directors as necessary for them to carry
out their duties.
Other uses and disclosures, besides those identified in this Notice,
will be made only as otherwise required by law or with your written
authorization. You may revoke any authorization at any time,
as previously provided in this Notice under “Your Health
This Notice is available on our website: brain-spine.com
For a downloadable and signable version of this form, see this pdf.Contact Us to Request an Appointment