Notice of Privacy Practices
NAJEEB THOMAS, MD
3798 Veterans
Memorial Blvd.
Suite 200
Metairie, LA 70002
Ph: (504) 454-0141		   Uses and disclosures that are not otherwise allowed shall be made only with an authorization pursuant to applicable law and the Privacy Rules. Use or disclosures of protected health information (PHI) for treatment, payment or health care operations as permitted in the Privacy Rules DO NOT REQUIRE an authorization.

PURPOSE:

To ensure that authorizations are used, and uses and disclosures are made pursuant to those authorizations, as required by the Health Insurance Portability and Accountability Act, Standards for Privacy of Individually Identifiable Health Information, 45 CFR Parts 160 and 164, Federal regulations, and applicable Louisiana Law.

PROCEDURE:

When a use or disclosure is not allowed by any other policy, PHI may be used or disclosed only with an authorization that meets the requirements of this policy according to the conditions specified in this policy.

Authorization request:

A. When physician wishes to use or disclose PHI in a way that requires an authorization, the individual or his personal representative will be requested to provide such an authorization.

B. This Authorization Form [Authorization Form (English Version)] [Authorization Form (Spanish Version)] will be used for authorizations requested on behalf of physician. It will be completed according to the Minimum Requirements described in the [Minimum Requirement Checklist for Valid Authorization] [see also additional guidance – page 3 this policy]

C. A copy of the signed authorization will be provided to the individual.

Authorizations not requested by physicianA. Whenever possible, others seeking an authorization from an individual to obtain PHI from OCF should be encouraged to use physician’s Authorization Form [Authorization Form (English Version)] [Authorization Form (Spanish Version)]. Individuals may not, however, be required to use that form.

B. When another form is used, it will be checked for compliance with this Policy by using [Minimum Requirement Checklist for Valid Authorization] [see also additional guidance – page 3 this policy]

Extent of use or disclosure

Disclosures pursuant to an authorization will be limited to the PHI specified in the authorization.

Revocation of authorizations

An individual may revoke an authorization by providing written notice of the revocation, except to the extent that:

(i) physician has taken action in reliance thereon; or

(ii) If the authorization was obtained as a condition of obtaining insurance coverage and another other law provides the insurer with the right to contest a claim under the policy or the policy itself.

Accounting for disclosures

Any disclosure of PHI under this policy is NOT required to be included in an accounting of disclosures as required by the Privacy Rule.

Documentation

Any signed authorization under this policy MUST be documented and retained as required by the Policies & Procedures Development and Retention Policy

Additional Guidance:

MINUMUM REQUIREMENT CHECKLIST

A valid authorization must meet at least the following requirements and must be written in plain language:

1. It must contain:

a. A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion.

b. The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure.

c. The name or other specific identification of the person(s), or class of persons, to whom OCF may make the requested use or disclosure.

d. A description of each purpose of the requested use or disclosure. The statement “at the request of the individual” is a sufficient description of the purpose when an individual (patient) initiates the authorization and does not, or elects not to, provide a statement of the purpose.

e. An expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure. The statement “end of the research study,” “none,” or similar language is sufficient if the authorization is for a use or disclosure of protected health information for research, including for the creation and maintenance of a research database or research repository.

f. A statement of the individual’s right to revoke the authorization in writing and the exceptions to the right to revoke, together with a description of how the individual may revoke the authorization.

g. A statement of [Covered Entity’s Name]’s ability or inability to condition treatment on the authorization, by stating either (A) [Covered Entity’s Name] may not condition treatment on whether the individual signs the authorization when the prohibition on conditioning of authorizations described below applies; or (B) the consequences to the individual of a refusal to sign the authorization when [Covered Entity’s Name] can properly condition treatment on failure to obtain such authorization.

h. A statement that the information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer be protected by the Privacy Rules.

i. The signature of the individual and the date.

j. A description of signer’s authority to act for the individual, if a personal representative of the individual signs the authorization.

2. If the authorization is for marketing[Covered Entity’s Name] must include a statement acknowledging if direct or indirect remuneration is given to [Covered Entity’s Name].

3. The expiration date must not have passed or the expiration event must not be known by [Covered Entity’s Name] to have occurred.

4. The authorization must be filled out completely, with respect to 1(a) through 1(i), above if applicable.

5. The authorization is not known by [Covered Entity’s Name] to have been revoked as provided below.

6. Any material information in the authorization is not known by [Covered Entity’s Name] to be false.

7. It may not be combined with any other document to create a compound authorization, except as follows:

· An authorization for the use or disclosure of protected health information for a research study may be combined with any other type of written permission for the same research study, including another authorization for the use or disclosure of protected health information for such research or consent to participate in such research.

· An authorization for a use or disclosure of psychotherapy notes may only be combined with another authorization for a use or disclosure of psychotherapy notes.

· An authorization under this section, other than an authorization for a use or disclosures of psychotherapy notes, may be combined with any other such authorization under this section, except when a covered entity has conditioned the provision of treatment, payment, enrollment in the health plan, or eligibility for benefits under paragraph (b)(4) of this section on the provision of one of the authorizations.

8. The provision to an individual of treatment, payment, may not be conditioned on the provision of the authorization, except that:

· Research-related treatment may be conditioned on provision of an authorization for the use or disclosure of protected health information for such research under this section;

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