Feasterville Family Practice LLP
523 Bustleton Pike
Feasterville, PA 19053
phone: 215-355-7900 fax: 215-355-9005
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 any questions about this notice, please contact the Privacy Officer,
Chris Baker, at Feasterville Family Practice, 523 Bustleton Pike, Feasterville,
PA 19053 (215)355-7900.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is
personal. We are committed to protecting medical information about you. We
create a record of the care and services you receive at Feasterville Family
Practice. We need this record to provide you with quality care and to comply
with certain legal requirements. This notice applies to all of the records of
your care generated by our Practice. This notice will tell you about the ways in
which we may use and disclose medical information about you. We also
describe your rights and certain obligations we have regarding the use and
disclosure of medical information. We are required by law to:
make sure that medical information that identifies you is kept private;
give you this notice of our legal duties and privacy practices concerning
medical information about you; and
follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
We use and disclose medical information in many ways. 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 medical information about you to provide
you with medical treatment or services. We may disclose medical information
about you to doctors, nurses, technicians, nursing and medical students, or
hospital personnel who are involved in taking care of you. For example, a doc
tor treating you for a broken leg may need to know if you have diabetes
because diabetes may slow the healing process. In addition, the doctor may
need to tell the dietitian if you have diabetes so that we can arrange for
nutritional counseling. We also may share medical information about you in
order to coordinate the different things you need, such as prescriptions, lab
work and diagnostic testing. We also may disclo9se medical information about
you to people who may be involved in your medical care such as family
members, clergy, rehabilitation centers, etc.
For Payment. We may use and disclose medical information about you
so that the treatment and services you receive at Feasterville Family Practice
may be billed for and payment may be collected from you or on your behalf
from an insurance company or a third party. For example, we may need to
give your health plan information about testing that you received at our
Practice so your health plan will pay us or reimburse you for those services.
We may also tell your health plan about a treatment you are going to receive
to obtain prior approval or to determine whether your plan will cover the
For Health Care Operations. We may use and disclose medical
information about you for our Feasterville Family Practice operations. These
uses and disclosures are necessary to run our organization and make sure
that all of our patients receive quality care. For example, we may use medical
information to review our treatment and services and to evaluate the
performance of our staff in caring for you. We may also combine medical
information about many Feasterville Family Practice patients to decide what
additional services our Practice should offer, what services are not needed,
and whether certain new treatments are effective. We may also disclose
information to doctors, nurses, technicians, nursing and medical students and
other personnel for review and learning purposes. We may also combine the
medical information we have with medical information from other similar
organizations to compare how we are doing and see where we can make
improvements in the care and services we offer. We may remove information
that identifies you from this set of medical information so others may use it to
study health care and health care delivery without learning who the specific
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 Feasterville Family Practice.
Treatment Alternatives. We may use and disclose medical information
to tell you about or recommend possible treatment options 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.
Individuals Involved in Your or Payment for Your Care. We may release
medical information about you to a friend or family member who is involved in
your medical care. We may also give information to someone who helps pay
for your care. We may also tell your family or friends your condition and that
you have been seen in our office. In addition, we may disclose medical
information about you to a friend or family member should an emergent
situation arrive while you are at our office.
As Required By Law. We will disclose medical information about you
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 medical information about you 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 only be to someone able to
help prevent the threat.
For All Other Uses and Disclosures. All other uses and disclosures of
information not contained in this Notice of Privacy Practices will not be
disclosed without your authorization.
Organ and Tissue Donation. If you are an 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 medical information about you 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 medical information about
you for worker’s compensation or similar programs. These programs provide
benefits for work-related injuries or illness.
Public Health Risks. We may disclose medical information about you
for public health activities. These activities generally include the following:
• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child abuse 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 condition;
• to notify the appropriate government authority if we believe a patient has
been the victim of abuse, neglect or domestic violence. We will only make this
disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may disclose medical information to a
health oversight agency for activities authorized by law. These oversight
activities include, for example, audits, investigations, 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 medical information about you in response to a court or
administrative order. We may also disclose medical information about you in
response to a subpoena, discovery request, or other lawful process by
someone else involved in the dispute, but only if efforts have been made to tell
you about the request or to obtain an order protecting the information
Law Enforcement. We may release medical information if asked to do
so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar
• To identify or locate a suspect, fugitive, material witness, or missing
• 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 conduct;
• About criminal conduct at the hospital; 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
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 patients to funeral
directors as necessary to carry out their duties.
National Security and Intelligence Activities. We may release medical
information about you to authorized federal officials for intelligence,
counterintelligence, and other national security activities authorized by law.
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 institution.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about
Right to Inspect and Copy. You have the right to inspect and copy
medical information that may be used to make decisions about your care.
Usually, this includes medical and billing records, but does not include
psychotherapy notes. To inspect and copy medical information that may be
used to make decisions about you, you must submit your request in writing to
Chris Baker, Privacy Officer. If you request a copy of the information, we may
charge a fee for the costs of copying, mailing or other supplies associated with
your request. We may deny your request to inspect and copy in certain very
limited circumstances. If you are denied access to medical information, you
may request in writing, that the denial be reviewed. Another licensed health
care professional chosen by Feasterville Family Practice, LLP will review your
request and the denial. The person conducting the review will not be the
person who previously denied your request. We will comply with the outcome
of the review.
Right to Amend. If you feel that medical information we have about you
is incorrect or incomplete, you may ask us to include additional information in
your medical record. You have the right to request an amendment for as long
as all of the information, both old and new, is kept by or for Feasterville Family
Practice, LLP. To request an amendment, your request must be made in
writing and submitted to our Privacy Officer. In addition, you must provide a
reason that supports your request. We may deny your request for an
amendment if it is not in writing or does not include a reason to support the
request. In addition, we may deny your request if you ask us to amend
• Was not created by us, unless the person or entity that created the
information is no longer available to make the amendment;
• Is not part of the medical information kept by or for our Practice;
• Is not part of the information which you would be permitted to inspect
and copy; or
• Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request
an” accounting of disclosures.” This is a list of the disclosures we made of
medical information about you, excluding disclosures for the purpose of
treatment, payment and healthcare operations. To request this list or
accounting of disclosures, you must submit your request in writing to the
Administrator. Your request must state a time period, which may not be longer
than six years. Your request should indicate in what form you want the list (for
example, on paper or electronically). 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 the 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 for treatment, payment or health care operations. 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 care, like a
family member or friend. We are not required to agree to your request. 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 our Privacy Officer. 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 Communication. 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 only contact you at
work or by mail. To request confidential communication, you must make your
request in writing to our Privacy Officer. We will not ask you the reason for
your request. We will accommodate all reasonable requests. Your request
must tell us how or where you wish to be contacted. If you do not tell us how
or where you wish to be contacted, we do not have to follow your request.
Right to Restrict Release of Information for Certain Services. You have
the right to restrict the disclosure of information regarding services for which
you have paid in full or on an out of pocket basis. This information can be
released only upon your written authorization. A form is available for you to fill
out with this restriction information.
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 at any time. Even if
you have agreed to receive this notice electronically, you are entitled to a
paper copy of this notice.
Right to Breach Notification. You have the right to be notified of any
breach of your healthcare information.
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 in our office. The notice will contain
on the first page, the effective date. In addition, copies are available in our
If you believe your privacy rights have been violated, you may file a complaint
with our practice or with the Secretary of the Department of Health and Human
Services. To file a complaint, please write to the Privacy Officer at Feasterville
Family Practice, 523 Bustleton Pike, Feasterville, PA 19053. All complaints
must be submitted in writing. You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
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.