Kentucky Orthopedic Clinic

Resources And Forms

Dear Patient:

Physicians have always protected the confidentiality of health information. Today, state and federal laws also attempt to ensure the confidentiality of this sensitive information.

The federal government has published regulations designed to protect the pricacy of your health information. This "privacy rule" protects health information that is maintained by physicians, hospitals, other health care providers and health plans. Physicians must comply with the Privacy Rule's standards for protecting the confidentiality of your health information by April 14, 2003.

This new regulation protects virtually all patients' information. Every time you see a physician, are admitted to the hospital, fill a prescription, or send a claim to a health plan, your physician, the hospital or other health care provider will need to consider the privacy rule. All health information including paper records, oral communications, and electronic formats (such as e-mail) are protected by the privacy rule.

The privacy rule also provides you certain rights, such as the right to have access to your medical records. However, there are certain exceptions to these rights. We also take precautions in our office to safeguard your health information. Please feel free to ask your physician or our privacy officer about exercising your rights or how your health information is protected in our office.

The Notice of Private Practices attached to this letter explains our privacy practices. It contains very important information about how your confidential health information is handled by our office. It also describes how you can exercise your rights with regard to your protected health information.

Please let us know if you have any questions about our Notice of Privacy Practices. You may contact our Privacy Officer at 606-248-0050 or discuss any questions you may have with your physician.


This notice describes how medical information about you may be used and disclosed and how you can have access to this information. Please review if carefully.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment of 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 information that may identify you, and that relates to your past, present, or future physical or mental health or condition and related health care services.

Understanding Your Health Record/Information

Each time you visit a physician, hospital, or other healthcare provider, a record of your visit if made. Usually, this record contains your symptoms, examination and test results, diagnosis, treatment, and a plan for future care or treatment. This information, often referred to as your medical record, serves as a:

  • Basis for planning your care and treatment
  • Method of communication among the many health professionals who participate in your care
  • Legal document describing the care you received
  • Means by which you or a third-party payer can verify that services billed were actually provided
  • A tool in educating health professionals
  • A source of data for medical research
  • A source of information for public health officials charged with improving the health of the nation
  • A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in the record and how your health information is used helps you to
  • Ensure its accuracy
  • Better understand who, what, when, where, and why others may access your health information
  • Make more informed decisions when authorizing disclosure to others

  • Your Health Information Rights

    Although your medical record is the physical property of the practice or facility that compiled it, you have the right to:
    • Request a restriction on certain uses and disclosures of your information
    • Obtain a paper copy of the notice of information practices upon request
    • Inspect and obtain a copy of your medical and billing records that your physician and the practice uses for making decisions about you
    • Request an amendment to your medical record
    • Obtain an accounting of certain disclosures of your health information
    • Request confidential communications of your health information by alternative means or at alternative locations
    • Revoke your authorization to use or disclose health information except to the extent that action has already been taken

    Our Responsibilities

    This practice is required to:
    • Maintain the privacy of your health information
    • Notify your of our legal obligations and privacy policies with respect to information we collect and maintain about you
    • Abide by the terms of this notice
    • Notify you if we are unable to agree to a requested restriction
    • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

    We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your appointment.

    We will not use or disclose your health information without your authorization, except as described in this notice.

    For More Information or to Report a Problem

    If you have questions and would like additional information, you may contact our Privacy Officer _______________ at 606-248-0050.

    If you believe your privacy rights have been violated, you can file a complaint with the Office Manager, or with the Secretary of Health and Human Services. We will not retaliate against you for filing a complaint.

    Examples of Disclosures for Treatment, Payment and Health Operations

    Your health information may be used and disclosed by your physician, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your health information may also be used and disclosed to pay your health care bills and to support the operation of the physician's practice.

    We will use your health information for treatment.

    For example: Information obtained by a nurse, physician, or other members of our staff will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care.

    We will use your health information for payment.

    For example: a bill may be sent to you or to an insurance plan. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
    We will use your health information for regular health operations, in order to support the business activities of the physician's practice.

    For example: We may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

    Business Associates: There are some services provided in our organization through contacts with business associates. Examples include billing or transcription services. When these services are contracted, we may disclose your health information to our business associate so they can perform the job we've asked them to do. To protect your health information, however, we require the business associate to sign a written contract to appropriately safeguard your information.

    Marketing: We may contact you to provide information about treatment alternative or other health-related benefits and services that may be of interest to you. Your name and address may be used to send you a newsletter about our practice and the services we offer. You may contact our Privacy Contact to request that these materials not be sent to you.

    Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization
    Other uses and disclosures of your health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that we have already taken an action in reliance on the use or disclosure indicated in the authorization.

    Other Permitted and Required Uses of Disclosures That May Be Made With Your Authorization or Opportunity to Object

    Communication with family: Unless you object, health professionals, using their best judgment, may disclose to a family member, other relative, or close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition, or death.
    Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment.

    Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization, or Opportunity to Object

    To a limited extent, we may disclose health information in the following circumstances:

    • If required by law
    • For research purposes under a protocol to protect privacy
    • To Coroner, Funeral Directors, and Organ Donation Services
    • To the Food and Drug Administration (FDA) regarding adverse events
    • To Worker's Compensation
    • As required by law for Public Health purposes
    • To an appropriate public health authority in cases of abuse, neglect, consistent with federal and state laws
    • To the agents of a correctional institution, should you be an inmate
    • When appropriate circumstances apply, the information of individuals who are armed forces personnel may be disclosed for purposes related to military activity
    • For National Security purposes
    • For law enforcement purposes or in response to a valid subpoena
    • To a health oversight agency for activities authorized by law

    If you have any questions or complaints, please contact our Privacy Officer at:

    Dubin Orthopaedic Centre, P.S.C.
    705 N. 12th Street
    Middlesboro, KY 40965


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