ROCKY MOUNTAIN MEN’S CLINIC
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.

If you have questions about this notice or want more information, please contact: our Privacy Officer at (720) 372-1501. The effective date of this notice is May 1, 2017.

To appropriately treat you and receive payment for the services we provide, we need to obtain information from you. While we are not a “covered entity” and are not subject to federal requirements under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), we limit our use and disclosure of your information consistent with Colorado law.

We will use and disclose this information and other information we collect in the ways described below.
To help you understand how we will use and disclose your information we have put the different uses and disclosures into categories and give examples of each. All of the ways we use or disclose your information will fit into one of the categories listed below, but we cannot list all of the uses and discloses in each category.

We may use and disclose your health information for treatment, payment, and health care operations.

  • Treatment. We may use and disclose your information to provide you with medical treatment and services. Your information may be disclosed to individuals and facilities providing care to you. These individuals and facilities need your information to provide care, and to coordinate and provide services (such as prescriptions, lab tests, meals, and x-rays).
  • Payment. We may use and disclose your information to receive payment for the services and treatment provided to you. We use your information to create a bill and disclose your information when we send the bill to your insurance company, you, or a third party. The individual or entity paying the bill may request more information to determine whether the bill is covered by your insurance. We may tell your health plan about a treatment you are going to receive to get approval for payment or to determine whether your health plan will cover the treatment.
  • Health Care Operations.  We may use and disclose your information for health care operation purposes. Health care operations includes review of the care you receive for quality assessment, educational, business planning, and compliance plan purposes.
  • Appointment Reminders. We may provide appointment reminders to you. You may request in writing that we send reminders to a confidential or alternative address.
  • Treatment Alternatives. We may provide you with information about treatment alternatives and other health related benefits and services.
  • Waiting Rooms. 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 we are ready to begin your treatment.

We may also disclose your health information to outside entities without your consent or authorization in the following circumstances:

  • Required by Law. We disclose information as required by law. For example, we are required to report gunshot wounds to the police.
  • Public Health Purposes. We disclose information to health agencies as required by law for preventing or controlling disease. Examples are reporting of sexually transmitted, communicable, and infectious diseases.
  • To Prevent a Serious Threat to Health or Safety. We may disclose information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.
  • Research. Your information may be used by or disclosed to researchers for research approved by a privacy board or an institutional review board.
  • Health Oversight Activities. Your health information may be disclosed to governmental agencies and boards for investigations, audits, licensing, and compliance purposes.
  • Judicial and Administrative Proceedings. We may be required to disclose your health information to a court or for an administrative proceeding.
  • Law Enforcement Activities. We may be required to disclose your information as required by law, pursuant to a court order, warrant, subpoena, or summons.
  • Deceased Individual. We may disclose information for the identification of the body or to determine the cause of death.
  • Military and Veterans. If you are a member of the armed forces we may release information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.
  • Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official. This release must be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety or security of the correctional institution.
  • Organ and Tissue Donation. If you are an organ donor, we may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ bank, as necessary to facilitate organ or tissue donation.
  • Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs.
  • Specialized Governmental Functions. We may release information about you to authorized Federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
  • Business Associates. We sometimes work with outside individuals and businesses that help us operate our business successfully. We may disclose your health information to these business associates that that they can perform these tasks we hire them to do. Our business associates must provide us with certain written assurances that they will respect the confidentiality of your personal and identifiable health information.
  • Individuals Involved in Care. We may tell your friends, relatives and other caretakers information
    which is relevant to their involvement in your care.
  • Disaster Relief. We may disclose information about you to public or private agencies for disaster relief
    purposes.Except as provided above, we will obtain your written authorization prior to disclosure of your information for any other purpose. Specifically, written authorization is required prior to the disclosure of your information:
  • Psychotherapy Notes. We will not use or disclose your psychotherapy notes without a written authorization except as specifically permitted by law.
  • Marketing. We will not use or disclose your information for marketing purposes, other than face-to-face communications with you or promotional gifts of nominal value, without your written authorization.
  • Sale of Information. We will not sell your PHI without your written authorization, including notification of the payment we will receive. Where a disclosure is made under your written authorization, you have the right to revoke the authorization at any time. Revocation of an authorization must be in writing. The revocation is effective as of the date you provide it to RMMC and does not affect any prior disclosures made under the authorization.

Your Rights

  • You have the right to request a restriction on how information about you is used and disclosed.
  • You have the right to request communications with you be made at an alternative address or phone number.
  • You have the right to inspect and copy your medical record.
  • If you believe the information we have about you is incorrect or incomplete you may request that we amend your medical record.
  • You have the right to request a list of individuals and entities that received your health information for reasons other than treatment, payment, or healthcare operations.
  • You have the right to request a paper copy of this Notice.

Our Duties

  • We are required by law to maintain the privacy of your information and to provide you with this Notice of our legal duties and privacy practice regarding health information.
  • We are required to notify you if there is a breach of your unsecured information.
  • We are required to follow the terms of the current Notice.
  • We may change the terms of this Notice and the revised Notice will apply to all health information in our possession. If we revise this Notice, a copy of the revised Notice will be posted and a copy may be requested from our Privacy Officer at the number listed at the beginning of this form.

Questions and Complaints

If you have any questions regarding our privacy practices, desire to request an action related to your rights, or believe your privacy rights have been violated, please contact our Privacy Officer:

Jeff Dillon
Clinic Director
1780 South Bellaire Street, Suite 355
Denver, CO 80222
(720) 372-1501
Jeff@rmmensclinic.com

New Castle Rock Location

718 Maleta Lane, #201
Castle Rock, CO 80108
Tuesday & Thursday: 9am – 5pm
castlerock@rmmensclinic.com
 
720-889-3735

CENTRAL DENVER

303-828-9110
contactus@rmmensclinic.com
1780 S Bellaire Street, #355
Denver, CO 80222

Mon – Fri: 9am – 5pm
(Closed Sat & Sun)
Walk-ins Welcome

COLORADO SPRINGS

719-301-1141
contactsouth@rmmensclinic.com
5731 Silverstone Terrace, #250
Colorado Springs, CO 80919

Mon – Fri: 9am – 5pm
(Closed Sat & Sun)
Walk-ins Welcome

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