To receive service within a reasonable period of time.
To receive medically necessary services.
To be treated with respect and courtesy.
To receive all available information about your care and treatment, including risks and options.
To have your medical coverage explained to you.
To have all medical and personal records treated as confidential.
To participate in treatment decisions.
To refuse treatment.
To receive impartial access to treatment.
To receive a second opinion regarding any treatment plan.
To review or to receive a copy of your medical record subject to legal restrictions and reasonable copying charges.
To request review of your medical record by the physician, and to request corrections if necessary.
To be given information on how to file a complaint/grievance.
To formulate an advance directive if you have a life threatening illness or injury.
To provide, or have provided for you, an interpreter in your primary language.
Having appropriate identification, insurance, membership cards, coverage stickers, etc, at the time of the appointment
Keeping appointments or contacting this office in advance to cancel an appointment.
Fulfilling financial obligations at the time of service such as deductible or co-pay fees.
Providing complete and accurate information.
Following the health plan you and the physician agree on.
Being considerate of others
Providing legal documentation of guardianship of a minor being treated.
Providing a list of persons who may receive medical information about you, on your behalf, in an emergency.
YOUR PRIVACY RIGHTS
Protecting your privacy is important to Riverside Physician Network. Effective April 14, 2003, all
health care facilities and physicians are required by law to protect the privacy of your medical record and other
health information and to provide you with notice of their legal duties and privacy practices with respect to your
Protected Health Information.
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.
Riverside Physician Network and its affiliates, are required by law to maintain the privacy of
your health information and to provide you with notice of their legal duties and privacy practices with respect to
your Protected Health Information (PHI). PHI is any health information, which is identifiable to you. If you have
questions about any part of this notice or if you want more information about the privacy practices at Riverside Physician Network, please
contact the Provider Relations Manager.
Effective Date of This Notice: April 14, 2003
I. How Riverside Physician Network may Use or Disclose Your Health Information
Riverside Physician Network collects PHI from you and stores it in a chart and on a computer. This is your medical record.
The medical record is the property of Riverside Physician Network, but the information in the medical record belongs to you. Riverside Physician Network protects the
privacy of your PHI. The law permits Riverside Physician Network to use or disclose without written authorization your PHI for the following
- Treatment. Riverside Physician Network is a primary care medical group that offers a full spectrum of health care
treatment and services, using a provider network of employed and contracted physicians, as well as contracted
hospitals and specialty medical/surgical services ("Business Associates"). Medical treatment includes
but is not limited to:
- Preventive care (immunizations, flu shots, histories and physicals, screening exams, etc.)
- Diagnostic treatment (x-rays, lab tests, etc.)
- Specialty care (home health, dialysis, physical therapy)
- Palliative/hospice care
- Payment. We may use and disclose PHI to provide payment for services that we provide to you.
Payors are: insurance companies (including HMOs, PPOs, Medicare, etc.) employers, and others who arrange or pay
the cost of some or all of your health care. Your insurance company may release some or all of your PHI to the
primary policy holder.
- Regular Health Care Operations. Your PHI will be provided to Riverside Physician Network employees or "business
associates" who participate in meeting your health care needs. This includes but is not limited to:
scheduling appointments, appointment reminders, greeting you on arrival, assisting your physician during the
office visit, arranging referrals, and transcribing and maintaining your records. We may use your PHI to evaluate
the quality and competence of our physicians, nurses, and other health care workers.
- Information Provided to You. Upon your signed authorization, information will be released to
- Notification and Communication with Family. We may disclose your PHI to a family member, your
personal/legal representative (one who has a valid Power of Attorney for Health Care, a conservator, or a
guardian) or another person responsible for your care. If you are able and available to agree or object, we will
give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree
or object, our health professionals will use their best judgment in communication with your family and
- Required by Law. As required by law, we may use and disclose your PHI.
- Public Health. As required by law, we may disclose your PHI to public health authorities for
purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect;
reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions
to medications; and reporting disease or infection exposure.
- Health Oversight Activities. We may disclose your PHI to health agencies during the course of
audits, investigations, inspections, licensure, and other proceedings.
- Judicial and Administrative Proceedings. We may disclose your PHI in the course of any
administrative or judicial proceeding.
- Law Enforcement. We may disclose your PHI to a law enforcement official for purposes such as
identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or
subpoena and other law enforcement purposes.
- Deceased Person Information. We may disclose your PHI to coroners, medical examiners, and
- Organ Donation. We may disclose your PHI to organizations involved in procuring, banking, or
transplanting organs and tissues.
- Research. We may disclose your PHI to researchers conducting research that has been approved by
an Institutional Review Board.
- Public Safety. We may disclose your PHI to appropriate persons in order to prevent or lessen a
serious and imminent threat to the health or safety of a particular person or the general public.
- Worker's Compensation. We may disclose your PHI as necessary to comply with worker's
- Marketing. We may contact you to provide appointment reminders or to give you information about
other treatments or health-related benefits and services that may be of interest to you.
- Change of Ownership. In the event that Riverside Physician Network is sold or merged with another organization, your
PHI/record will become the property of the new owner.
II. When Riverside Physician Network May Not Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, Riverside Physician Network will not use or disclose your PHI
without your written authorization. If you do authorize Riverside Physician Network to use or disclose your PHI for another purpose, you may
revoke your authorization in writing at any time.
III. Your Health Information Rights
- You have the right to request restrictions on certain uses and disclosures of your PHI. However, Riverside Physician Network is not
required to agree to the restriction that you requested.
- Upon written request, you have the right to receive your PHI through a reasonable alternative means or at an
- You have the right to inspect and request a copy of your PHI. You should take note that, if you are a parent or
a legal guardian of a minor, certain portions of the minor's medical record will not be accessible to you.
- You have a right to request that Riverside Physician Network amend your PHI that is incorrect or incomplete. Riverside Physician Network is not required to
change your PHI and will provide you with information about the Riverside Physician Network denial process, and how you can disagree with
- You have a right to receive an accounting of disclosures of your PHI made by Riverside Physician Network, except that Riverside Physician Network does not have
to account for the disclosures described in parts 1 (treatment), 2 (payment), 3 (health care operations), and 4
(information provided to you), of section I of this Notice of Privacy Practices.
- You have a right to a paper copy of this Notice of Privacy Practices.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or
more of these rights, contact the Provider Relations Manager.
IV. Changes to this Notice of Privacy Practices
Riverside Physician Network reserves the right to amend this Notice of Privacy Practices at any time
in the future, and to make the new provisions effective for all information that it maintains, including information
that was created or received prior to the date of such amendment. Until such amendment is made, Riverside Physician Network is required by
law to comply with this Notice.
Complaints about this Notice of Privacy Practices or how Riverside Physician Network handles your PHI
should be directed to the Riverside Physician Network Patient Services Department.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a
formal complaint to:
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
You may also address your complaint to one of the regional
Offices for Civil Rights.