EFFECTIVE AS OF: January 11, 2004
Notice of Privacy Practices
THIS NOTICE DESCRIBES
HOW MEDICAL INFORMATION ABOUT YOU MAYBE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
OrthoMart, LLC creates a
record of the care, products and services you receive from us and a
record of the payment for such services. This record may also
include information about you received from other health care
providers, including information about your past, present or future
health or condition and related health services. We are committed to
protecting the confidentiality of all such health information about
you and maintained by us (your "health information").
This notice describes (1)
how we may use and disclose your health information to carry out
treatment or payment activities or to carry out the health care
operations of OrthoMart, LLC. and (2) your rights to access and
control your health information.
The privacy practices
described in this notice apply to all officers, employees, staff,
sales consultants, contractors and agents of OrthoMart, LLC, and to
their activities at the main office location in Norwalk, CT and all
sites of service in the United States. Your physician and other
health care providers may have different privacy practices and will
provide you with their own Notice of Privacy Practices.
- Uses and
Disclosures of Health Information
- Uses and
Disclosures for Treatment, Payment or Health Care Operations
Your health information
may be used by OrthoMart, LLC, our employees, staff, sales
consultants and other persons assisting us for
the purpose of providing health care services to you, seeking
payment for your health care, and supporting our health care
operations. We may disclose your health information to other
health care providers or other persons involved in your treatment,
to certain persons or entities involved in payment for your health
care and, with certain limitations, to other persons and entities
for health care operations purposes.
We will use and disclose your protected health information to
provide, coordinate, or manage your health care and related
services. For example, we may disclose your health information, as
necessary, to a home health agency that provides care to you. As
another example, we may provide health information to a physician to
whom you have been referred to ensure that the physician has the
necessary information to diagnose or treat you.
Payment: Your health
information will be used and disclosed, as needed, in order to bill
or obtain payment for your health care services. For example, we may
need to give health information about you to an insurance company in
order to receive payment on a claim that has been filed.
Operations: With certain
limitations, we may use or disclose your health information in order
to support the business activities and operations of OrthoMart, LLC.
These activities include, but are not limited to, quality of care
assessments, employee or product review, licensing or accreditation
activities, and conducting or arranging for certain other business
activities. For example, we may use and disclose your health
information in reviewing and assessing our treatment services and in
evaluating the performance of our staff and products. Or, for
example, we may disclose health information to persons involved in
reviewing our service as a Medicare supplier.
- Other Uses
Information About Health Alternatives. Benefits. or Services. We may use
your health information to send you reminders of appointments for
initial fittings or follow-ups or to give you information about
treatment alternatives or other health-related benefits and services
provided by us that may be of interest to you.
Required by Law. We may use and
disclose your health information as required by law. For example, we
may disclose information for the following purposes:
- As required for judicial and administrative proceedings;
- To report information
related to victims of abuse, neglect, or domestic violence; and
- To assist law
enforcement officials in their law enforcement duties
- As required by the
Secretary of the Department of Health and Human Services to
determine our compliance with the
Public Health Risks.
information may be used or disclosed for public health activities,
such as assisting public health
authorities or other legal authorities to prevent or control
disease, injury or disability, to track births and deaths, to report
reactions to medications or problems with health products, to notify
people of recalls of products, or to notify people who may have been
exposed to a disease or be at risk of contacting or spreading a
Health Oversight. We may
disclose health information to a health oversight agency for
activities authorized by law. These health oversight activities
include, for example, audits, investigations, inspections and
Involved in Your Care or Payment for Your Care. Unless you
object, we may disclose your health information to members of your
family or others involved in your care, if such disclosure is in
accordance with good medical practice.
Research. We may use
your health information for research purposes provided that an
institutional review board or privacy board has reviewed the
proposal and has established appropriate safeguards to ensure
privacy of your health information.
Serious Threat to
Health or Safety.
We may use and
disclose your health information in the event of an emergency to
prevent a serious threat to the health or safety of you or another
person. Any disclosure would be made only to someone reasonably able
to help prevent the threat.
Organ or Tissue
Donation. Your health
information may be used or disclosed for purposes of organ or tissue
donation as provided by law.
Functions. Your health
information may be disclosed for specialized government functions
such as the protection of the president or other public officials or
required reporting to military services.
Compensation. Your health
information may be used or disclosed for workers compensation or similar
Disputes. We may
disclose health information about you tin response to a subpoena,
discovery request or other lawful process but only if appropriate
efforts have been made to tell you about the request or to obtain an
order protecting the information requested.
Law Enforcement. We may release
health information if asked to do so by a law enforcement official
under certain circumstances, including, but not limited to reporting
criminal conduct, the location of the crime or the victim, in the
event of an emergency, to respond to a court order, subpoena
warrant, summons or similar process.
Coroner or Medical
Examiner. We may release
health information about you to a coroner or medical examiner.
Inmates. If you are an
inmate of a correctional institution or under the custody of a law
enforcement official, we may release your health information to the
institution or law enforcement official.
Other Permitted and
Required Uses and Disclosures. We will make
other disclosures of your health information only with your consent
or authorization or as required by law. You may revoke this
authorization, at any time, in writing, except to the extent that we
have taken an action in reliance on the use or disclosure indicated
in the authorization.
Protecting Health Information.
reflects the requirements of the federal privacy law and
confidentiality of medical records law in the State of Connecticut,
the location of our main office and your health information. If you
receive services in a State other than Connecticut, that state may
impose other restrictions or requirements on the use and disclosure
of health information. We will follow applicable state law that does
not conflict with federal law.
- Your Rights
Regarding Your Health Information
You have the following
rights regarding your health information maintained by us:
You have the right
to inspect and copy your health information. To inspect and
copy your health information, you must submit your request in
writing by mail or by fax to OrthoMart, LLC. At the address or fax
number listed below. If You request a copy of your health
information, we may charge a reasonable fee for the costs of
copying, mailing and supplies.
Your right to inspect may
be limited in some circumstances. For example, your right to inspect
and copy may not extend to information compiled in reasonable
anticipation of, or use in, a civil, criminal, or administrative
action or proceeding, information protected by federal privacy laws,
information that is prohibited from being re-disclosed, or
information relating to a research project if you have agreed to
suspend access in your consent to research. If we deny your request
to inspect and copy,
we will send you a written explanation that will include an
explanation of any review rights you might have.
You Have the Right
to Request a Restriction on the Use or Disclosure of Your Health
Information. You may ask us not to use
or disclose any part of your protected health information for the
purposes of treatment, payment or healthcare operations. You may
also request that any part of your protected health information not
be disclosed to family members or friends who may be involved in
your care or treatment. Your request must state the specific
restriction requested and to whom you want the restriction to apply.
We are not required to agree to a restriction that you may request
You May Have the
Right to Have Request Amendment of Your Health Information for
Information Kept as Part of a Record Set.
Your request must be in writing and sent by mail or by fax to
OrthoMart, LLC. at the address or fax listed below. We may deny your
request under certain circumstances. If we deny your request for
amendment, you have the right to file a statement of disagreement
with us and that statement will be included as part of your medical
record. We may prepare a rebuttal to your statement and will provide
you with a copy of any such rebuttal.
You Have the Right
to Receive an Accounting of Disclosures. You may
request an accounting of disclosures we have made of your health
information other than disclosures for treatment, payment or health
care operations, incidental disclosures, disclosures pursuant to an
authorization or certain other required disclosures. You must submit
your request in writing to us at the address or fax listed below.
Your request must state a time period that may not be longer than
six years and may not include dates before Apri114, 2003. We may
charge you a fee for providing a list of disclosures.
You Have the Right
to File a Complaint. You may
complain to us or to the Secretary of Health and Human Services if
you believe your privacy rights have been violated by us. You may
file a complaint with us by notifying our privacy officer at the
address or telephone number listed below. We will not retaliate
against you for filing a complaint.
Changes to this
Notice. We reserve the
right to change this notice and to make the revised or changed
notice effective for all health information we already have about
you as well as any information we receive in the future. We will
provide a revised notice to you at the time of your next fitting
date following the effective date of the revised notice. In
addition, you have the right to obtain a paper copy of this notice
at any time upon written request to us at the address or fax number
listed below. Our current notice will be available on our web site.
Protecting Your Health Information. The laws in
some states may permit greater access and control over your health
information than provided under federal law. If the law in the state
in which you receive services offers greater rights of access to and
control of your health information and does not conflict with
federal law, we will provide such access or control in accordance
with such law, to the extent it is applicable.
complaints or requests for restrictions, amendments or access to
records or requests for a copy of a notice of privacy practices
should be directed to:
PO Box 417
Westport, CT 06881
Attn: Privacy Officer
Tel: 203.854.5174 Fax: 888.958.5044