IN ACCORDANCE WITH FEDERAL LAW, THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Occupational Health Services (OHS-COMPCARE) and its associated organizations utilizes health information about you for treatment and clinical services, to release to employers or their designees for the purpose of their management of workplace surveillance, preventive health or worker’s compensation programs, to obtain payment for treatment and services, for administrative purposes, and to evaluate the quality of treatment or services provided. Your health information is contained in a medical record and within a secured patient information system that is physical property of OHS-COMPCARE.

This Notice covers your information at OHS-COMPCARE or its associated organizations; it does not cover your information in a provider’s office that is not employed by OHS-COMPCARE or its associated organizations. You may receive another notice when you go to other facilities to which OHS-COMPCARE may refer you for treatment.

How OHS-COMPCARE May Use or Disclose Your Information

OHS-COMPCARE and its associated organizations will use and disclose personal health 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 given examples of each. All of the ways we use of disclose your information will fit into one of the categories listed below, but we cannot list all of the uses and disclosures in each category.

For Treatment and Clinical Services: OHS-COMPCARE and its associated organizations may use your health information to provide you with medical treatment or clinical services. For example, information obtained by health care providers such as our physicians or other clinical staff will be recorded in your medical record. This information is necessary for health care providers to determine what treatment or service is necessary. The health care providers will also record actions taken in the course of your treatment and note how you respond to those actions. Other information may include medical history that is relevant to the particular treatment or service, ancillary studies, consults from other providers, physical rehabilitation records, lab studies etc. By way of example, medical information relevant to drug allergies will be included in the medical record in the event that it may apply to a particular treatment or service.

OHS-COMPCARE may also disclose your health information to outside health care providers for the purpose of treatment or clinical services to you. For example, medical record information relating to the treatment of a work related injury would be sent to the surgeon if a surgical consult were being considered.

For Payment: OHS-COMPCARE may use and disclose your health care information to receive payment for the treatment or clinical services provided to you. We will use the information to create a bill and disclose your information when we send the bill to the entity approving, processing or paying the bill. Such entities may include, but not limited to, third party administrators, insurance claims adjustor, managed care companies, case managers, your employer or prospective employer, division of workers’ compensation, or attorney’s. The individual or entity approving, processing or paying the bill may request more information to determine whether the bill will be paid. For pre-approval purposes, we may also disclose to an entity that will authorize payment for treatment, information about a clinical service or treatment that we feel you need.

For Health Care Operations: OHS-COMPCARE may use and disclose health information about you for internal operational purposes. Health care operations includes, but is not limited to, a review of the care you receive for quality assessment, risk management, educational, business planning and compliance purposes.

Appointments: OHS-COMPCARE may use your information to provide appointment reminders to you, a specialist to whom you have been referred, your employer designee, a case manager, or claims representative.

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

1.) To your employer designee(s) to the extent necessary to comply with regulations under the workers’ compensation or similar programs that provide benefits for work related injury or illnesses without regard to fault,

2.) To an employer designee(s) about an individual who is a member of the employer’s workforce or an applicant for a position within an employer’s workforce, if:

v The service has been requested and authorized by the employer for any type of workplace medical surveillance or employer sponsored preventive health program;

v The information consists of findings concerning a work-related illness or injury or workplace surveillance program;

v The information consists of findings that may place the individual or a co-worker at risk of imminent harm in the workplace;

v The information is required to comply with obligations under 29 CFR Part 1904-1928, 30 CFR Parts 50-90, 49 CFR Part 391 or under similar local, state or federal regulations, to record such illness or injury or to carry out responsibilities for workplace medical surveillance and safety;

v OHS-COMPCARE provides you with specific notice that the information will be disclosed to the employer designee.

3.) To prevent a serious threat to health or safety, we may disclose information about you to law enforcement or an identified victim.

4.) To meet requirements under the law. For example, we are required to report gunshot wounds to the police;

5.) For judicial and administrative proceeding sent to a legal authority;

6.) To report information related to victims of abuse, neglect, or domestic violence;

7.) To assist law enforcement officials in their law enforcement duties;

8.) To public health organizations as required by law for the purpose of preventing or controlling diseases such as hepatitis, HIV, TB etc.

9.) For health oversight activities as required by governmental agencies and boards for investigations, audits, licensing and compliance;

10.) For other disclosures approved under the Health Insurance Portability and Accountability Act.

Your Rights Regarding Your Personal Health Information:

1.) You have the right to request a restriction on how information about you is used and disclosed. If you want to request a restriction of use or disclosure of your information, contact the Privacy Officer at (816) 561-2105. We are not required to agree to any restriction on the use or disclosure of your information.

2.) You have the right to request communications with you be made at an alternative address or phone number. To request that communication be made at a different address or phone number, request to speak with the clinical manager and obtain a form to make your request.

3.) You have the right to inspect and copy your medical record. To inspect and copy your medical record a request must be made in writing on the form provided by OHS-COMPCARE. To obtain a form, contact the Privacy Officer at (816) 561-2105.

4.) If you believe the information we have about you is incorrect or incomplete you may request that we amend your medical record. Your request must be made in writing on the form provided by OHS-COMPCARE. To request the form, contact the Privacy Officer at (816) 561-2105.

5.) You have the right to receive an accounting of disclosures, a list of individuals and entities that received your health information. Your accounting will not include disclosures for reasons including treatment, payment, healthcare operations, disclosures made to you, disclosures made pursuant to an authorization, disclosures under workers’ compensation system or other workplace surveillance program, disclosure for service requested and authorized by your employer for any type of workplace medical surveillance or employer sponsored preventive health program; disclosures that may place you or a co-worker in significant and imminent harm in the workplace, disclosures required to comply with obligations under 29 CFR Part 1904-1928, 30 CFR Parts 50-90, 49 CFR Part 391 or under similar local, state or federal regulations, to record such illness or injury or to carry out responsibilities for workplace medical surveillance and safety, incidental disclosures, disclosures for notification purposes, disclosures as part of a limited data set, or disclosures for the purpose of law enforcement, national security or intelligence purposes, public or disaster relief. Your accounting will also not include any disclosure prior to April 14, 2003. You may receive one (1) free accounting during any twelve (12) month period of time. If you request more than one (1) accounting, you will be charged the current fee for a one (1) year accounting and additional fees for each additional year up to six (6) years. You will be notified of the fee in advance of your request.

6.) You have the right to request a paper copy of this notice.

Obligations of OHS-COMPCARE:

1.) We are required to maintain the privacy and security of protected health information.

2.) We are required to provide you with this notice of our legal duties and privacy practice with the respect to your health information. OHS-COMPCARE must follow the terms of the current notice.

3.) We are required to accommodate reasonable written requests that you may make to communicate health information by alternative means or at alternative locations. Where applicable, any additional expenses related to this accommodation will be disclosed in advance and are the responsibility of the requesting party.

4.) We are required to obtain your written authorization to use or disclose your health information for reasons other than those listed above or as permitted under law.

OHS-COMPCARE reserves a right to change its information practices and to make new provisions affective for all protected health information we maintain. Revised notices will be made available to you upon any successive visit to our clinical facility or upon your request from the Privacy Officer at (816) 561-2105.