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 any
questions about this notice, please contact
Waltham Diabetes Center 42 Weston Street. Waltham, MA 02453.
This notice describes the
" The Waltham Diabetes Center, LLC.
" Any health care professional
authorized to enter information into your medical chart or
" All departments and units of
Waltham Diabetes Center.
" Any member of a volunteer
group we allow to help you while you a part of the research
" All employees, staff and
other research personnel.
This notice describes the ways
in which we may use and disclose your medical information. It
also describes your rights and certain obligations we have
regarding the use and disclosure of your medical information.
We are required by law to:
" ensure that medical information that identifies you is kept
" give you this notice of our legal duties and privacy practices
with respect to medical information about you; and
" follow the terms of the notice that is currently in effect.
Understanding Your Health Record/Information
Each time you visit a hospital, physician, research facility, or
other healthcare provider, a record of your visit is made. This
record typically contains your symptoms, medical history,
examination, test results, diagnoses, treatment, and a plan for
future care or treatment. This information, often referred to as
your health or medical record, serves as a:
" basis for planning your care
" means of communication among the many health professionals who
contribute to 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 source of data for facility planning and marketing
" 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 your
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
WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following describes
different ways that we are permitted to use and disclose medical
information. For each category of uses or disclosures we will
explain what we mean and try to give some examples. Not every
use or disclosure in a category will be listed. However, all of
the ways we are permitted to use and disclose information will
fall within one of the categories.
" For Treatment. We may use your medical information to provide
you with medical treatment or services. We may disclose medical
information about you to doctors, nurses, technicians, medical
students, or other personnel at Waltham Diabetes Center and outside medical
providers such as a hospital which is involved in caring for and
following your progress. For example, different departments of a
hospital may share medical information about you in order to
coordinate the different services/treatments you need, such as
prescriptions, lab work, and x-rays. We may also disclose
medical information about you to people who may be involved in
your medical care after you leave The Waltham Diabetes Center,
such as a person you have designated, home health services,
clergy, or others who provide services that are part of your
" For Payment. We may use and
disclose your medical information so that Waltham Diabetes
Center may correctly pay for any medical services or treatments
you receive outside of Waltham Diabetes Center.
" For Health Care Operations. We may use and disclose your
medical information for research/clinical operations. These uses
and disclosures are necessary to run The Waltham Diabetes Center
and make sure that all of our volunteers receive quality care.
We may combine medical information about many research
volunteers to decide if certain new treatments are effective. We
may also disclose information to doctors, nurses, technicians,
medical students, and other personnel for review and learning
purposes. We may remove information that identifies you from
this set of medical information so others may use it to study
research and research practice without learning who the specific
volunteers are i.e., Arthritis Foundation, American Diabetes
Association. We may also combine the medical information we have
with medical information from other research facilities to
compare how we are doing and see where we can make improvements
in the care and services we offer.
" Appointment Reminders. We
may use and disclose medical information to contact you as a
reminder that you have an appointment for treatment or medical
care at The Waltham Diabetes Center.
" Treatment Alternatives. We may use and disclose medical
information to tell you about or recommend possible treatment
options, medical research, or alternatives that may be of
interest to you.
" Health-Related Benefits and
Services. We may use and disclose medical information to tell
you about health-related benefits or services that may be of
interest to you.
" Research. We may disclose information to researchers when an
institutional review board that has reviewed the research
proposal and established protocols to ensure the privacy of your
health information has approved their research.
" As Required By Law. We will disclose your medical information
when required to do so by federal, state or local law.
" To Avert a Serious Threat to Health or Safety. We may use and
disclose your medical information when necessary to prevent a
serious threat to your health and safety or the health and
safety of the public or another person. Any disclosure, however,
would be only to someone able to help prevent the threat.
" Special Situations - We may disclose medical information about
you to an entity assisting in a disaster relief effort so that
your family can be notified about your condition, status and
" Organ and Tissue Donation. If you are a potential organ donor,
we may release medical information to organizations that handle
organ procurement or organ, eye or tissue transplantation or to
an organ donation bank, as necessary, to facilitate organ or
tissue donation and transplantation.
" Military and Veterans. If you are a member of the armed
forces, we may release your medical information as required by
military command authorities. We may also release medical
information about foreign military personnel to the appropriate
foreign military authority.
" Workers' Compensation. We may release your medical information
for workers' compensation or similar programs. These programs
provide benefits for work-related injuries or illness.
" Public Health Risks. We may disclose your medical information
for public health activities. These activities generally include
" to prevent or control disease, injury or disability;
" to report births and deaths;
" to report child abuse and/or neglect;
" to report reactions to medications or problems with products;
" to notify people of recalls of products they may be using;
" to notify a person who may have been exposed to a disease or
may be at risk for contracting or spreading a disease or
" to notify the appropriate government authority if we believe a
patient has been the victim of abuse, neglect or domestic
violence. We will make this disclosure only if you agree or when
required or authorized by law.
" Health Oversight Activities. We may disclose your medical
information to a health oversight agency for activities
authorized by law. These oversight activities include, audits,
investigations, inspections, and licensure. These activities are
necessary for the government to monitor the health care system,
government programs, and compliance with civil rights laws.
" Lawsuits and Disputes. If you are involved in a lawsuit or a
dispute, we may disclose your medical information in response to
a court or administrative order. We may also disclose your
medical information in response to a subpoena, discovery
request, or other lawful process by someone else involved in the
dispute, but we will do so only if efforts have been made to
tell you about the request or to obtain a court order protecting
the information requested.
" Law Enforcement. We may release your medical information if
asked to do so by a law enforcement official in accordance with
" In response to a court order, subpoena, warrant, summons or
" To identify or locate a suspect, fugitive, material witness,
or missing person;
" About the victim of a crime if, under certain limited
circumstances, we are unable to obtain the person's agreement;
" About a death we believe may be the result of criminal
" About criminal conduct at Waltham Diabetes Center; and
" In emergency circumstances to report a crime; the location of
the crime or victims; or the identity, description or location
of the person who committed the crime.
" Coroners, Medical Examiners and Funeral Directors. We may
release medical 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
medical information about research volunteers to funeral
directors or designees as necessary to carry out their duties.
" National Security and Intelligence Activities. We may release
your medical information to authorized federal officials for
intelligence, counterintelligence, and other national security
activities authorized by law.
" Protective Services for the President and Others. We may
disclose your medical information to authorized federal
officials so they may provide protection to the President, other
authorized persons or foreign heads of state or conduct special
" Inmates. If you are an inmate of a correctional institution or
under the custody of a law enforcement official, we may release
medical information about you to the correctional institution or
law enforcement official. This release would 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 and security of the correctional
YOUR RIGHTS REGARDING MEDICAL
INFORMATION ABOUT YOU.
You have the following rights regarding medical information we
maintain about you:
" Right to Inspect and Obtain a Copy. You have the right to
inspect and obtain a copy of your medical information that may
be used to make decisions about your care. This request usually
includes medical and billing records but does not include
psychotherapy notes. In such case we would refer you to your
To inspect and obtain a copy
of your medical information that may be used to make decisions
about you, you must submit your request in writing to the Health
Information , Waltham Diabetes Center 42 Weston Street. Waltham, MA 02453. If
you request a copy of the information, we may charge a fee for
the costs of copying, mailing or other supplies associated with
We may deny your request to inspect and obtain a copy in certain
very limited circumstances. If you are denied access to your
medical information, you may request that the denial be
reviewed. Another licensed health care professional chosen by
the Waltham Diabetes Center will review your request and the denial. The person
conducting the review will not be the person who denied your
request. We will comply with the outcome of the review.
" Right to Amend. If you think that the medical information we
have about you is incorrect or incomplete, you may ask us to
amend the information. You have the right to request an
amendment for as long as the information is kept by or for
Waltham Diabetes Center. Your request for an amendment will become a legal part
of your medical record, to be sent out in addition to the rest
of the record whenever a request for copies is received. No part
of the original documentation can legally be destroyed.
To request an amendment, your
request must be made in writing and submitted to the Health
Information , The Waltham Diabetes Center 42 Weston Street. Waltham,
MA 02453. In addition, you must provide a reason that supports
We may deny your request for an amendment if it is not in
writing or does not include a reason to support the request. We
may also deny your request if you ask us to amend information
" Was not created by us, unless the person or entity that
created the information is no longer available to make the
" Is not part of the medical information kept by or for The
Waltham Diabetes Center;
" Is accurate and complete.
" Right to Request an Accounting of Disclosures. You have the
right to request an "accounting of disclosures." This is a list
of the disclosures we may have made of your medical information
without your authorization and the release was not part of
treatment, payment and healthcare operations.
To request this list or
accounting of disclosures, you must submit your request in
writing to the Health Information , The Waltham Diabetes Center,
42 Weston Street. Waltham, and MA 02453. Your request must state a
time period, which may not be longer than six years and may not
include dates before April 14, 2003. The first list you request
within a 12-month period will be free. For additional lists, we
may charge you for the costs of providing the list. We will
notify you of the cost involved and you may choose to withdraw
or modify your request at that time before any costs are
" Right to Request
Restrictions. You have the right to request a restriction or
limitation on the medical information we use or disclose about
you concerning your research relationship with us.
You also have the right to request a limit on the medical
information we disclose about you to someone who is involved in
your care or the payment for your research participation, such
as a family member or friend.
We are not required to agree
to your request for restrictions. If we do agree, we will comply
with your request unless the information is needed to provide
you emergency treatment.
To request restrictions, you must make your request in writing
to the Health Information , The Waltham Diabetes Center, 42
Weston Street. Waltham, MA 02453. In your request, you must tell us (1)
what information you want to limit; (2) whether you want to
limit our use, disclosure or both; and (3) to whom you want the
limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications. You have the right
to request that we communicate with you about medical matters in
a certain way or at a certain location. For example, you can ask
that we contact you only at work or by mail.
To request confidential
communications, you must make your request in writing to Health
Information, The Waltham Diabetes Center 42 Weston Street. Waltham, MA
02453. We will not ask you the reason for your request. We will
attempt to accommodate all reasonable requests. Your request
must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to a
paper copy of this notice. You may ask us to give you a copy of
this notice at any time. Even if you have agreed to receive this
notice electronically, you are still entitled to a paper copy of
You may obtain a copy of this
notice at our website, www.walthamdiabetes.com. To obtain a
paper copy of this notice, please contact the Health
Information, The Waltham Diabetes Center, 42 Weston Street. Waltham,
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right
to make the revised or changed notice effective for medical
information we already have about you as well as any information
we receive in the future. We will post a copy of the current
notice at Waltham Diabetes Center. The notice will contain on the first page, in
the top right-hand comer, the effective date. In addition, each
time you volunteer with us, we will offer you a copy of the
current notice in effect.
If you believe your privacy rights have been violated, you may
file a complaint with The Waltham Diabetes Center or with the
Secretary of the Department of Health and Human Services. To
file a complaint with The Waltham Diabetes Center, contact
Health Information , Waltham Diabetes Center , 42 Weston Street Waltham MA
02453. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL
Other uses and disclosures of medical information not covered by
this notice or the laws that apply to us will be made only with
your written permission.
If you provide us permission to use or disclose medical
information about you, you may revoke that permission, in
writing, at any time. If you revoke your permission, we will no
longer use or disclose medical information about you for the
reasons covered by your written authorization. You understand
that we are unable to take back any disclosures we have already
made with your permission, and that we are required to retain
our records of the care that we provided to you.