|Meet the Doctor||
Donald D. Berg, M.D.
Serving Southeast Iowa Since 1975
DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT
Effective Date: April
If you have any questions about this notice, please
The Office of Donald D Berg MD PC
of This Privacy Notice
This Notice of Privacy
Practices describes how we may use and disclose your protected health
information to carry out treatment, initiate payment, or conduct health
care operations and for other purposes that are permitted or required by
law. The medical practice reserves the right to make changes in the Notice of
Privacy Practices. The
Notice describes your rights to access and control your protected health
information. “Protected health information” is information about
you, including demographic information, that may identify you and that
relates to your past, present or future physical or mental health or
condition and related health care services.
Who Will Follow This Notice:
notice describes the privacy policies of our practice and that of:
Pledge Regarding Medical Information
understand that medical information about you and your health is
personal, and we are committed to protecting it.
A record of the care and services you receive at this practice is
created and maintained at this location.
This notice applies to all of those records of your care.
required by law to:
How We May Use And Disclose Medical Information
following categories describe ways that we use and disclose medical
information. Examples of
each category are included. Not
every use or disclosure in each category is listed; however, all of the
ways we are permitted to use and disclose information falls into one of
Treatment: We may use
medical information about you to provide, coordinate, or manage your
medical treatment or services. We
may disclose medical information about you to other physicians or health
care providers who are or will be involved in taking care of you.
For example, we would disclose your protected health information,
as necessary, to a home health agency that provides care to you. Another
example is that your protected health information may be provided to a
physician to whom you have been referred to ensure that the physician
has the necessary information to diagnose or treat you.
Healthcare Operations: We
may use or disclose, as-needed, your protected health information in
order to support the business activities of our practice. These
activities include, but are not limited to, quality assessment
activities, employee review activities, training of medical students,
and conducting or arranging for other business activities. For example,
we may disclose your protected health information to medical school
students that see patients at our office. We may call you by name in the
waiting room when your physician is ready to see you. We may use or
disclose your protected health information, as necessary, to contact you
to remind you of your appointment.
may share your protected health information with third party “business
associates” that perform various activities (e.g., billing,
transcription services) for the practice. Whenever an arrangement
between our office and a business associate involves the use or
disclosure of your protected health information, we will have a written
contract that contains terms that will protect the privacy of your
protected health information.
We may use or disclose your protected health
information, as necessary, to provide you with information about
treatment alternatives or other health-related benefits and services
that may be of interest to you. For example, your name and address may
be used to send you a newsletter about our practice and the services we
offer. You may contact our Privacy Officer to request that these
materials not be sent to you.
and Disclosures of Protected Health Information Based Upon Your Written
Other uses and disclosures of
your protected health information will be made only with your written
authorization, unless otherwise permitted or required by law as
described below. You may revoke this authorization, at any time, in
writing, except to the extent that your physician or the physician’s
practice has taken an action in reliance on the use or disclosure
indicated in the authorization.
Permitted and Required Uses and Disclosures That May Be Made With Your
Consent, Authorization or Opportunity to Object
We may use and disclose your
protected health information in the following instances. You have the
opportunity to agree or object to the use or disclosure of all or part
of your protected health information. If you are not present or able to
agree or object to the use or disclosure of the protected health
information, then your physician may, using professional judgment,
determine whether the disclosure is in your best interest. In this case,
only the protected health information that is relevant to your health
care will be disclosed.
Involved in Your Healthcare:
Unless you object, we may disclose to a member of your family, a
relative, a close friend or any other person you identify, your
protected health information that directly relates to that person’s
involvement in your health care. If you are unable to agree or object to
such a disclosure, we may disclose such information as necessary if we
determine that it is in your best interest based on our professional
judgment. We may use or disclose protected health information to notify
or assist in notifying a family member, personal representative or any
other person that is responsible for your care of your location, general
condition or death. Finally, we may use or disclose your protected
health information to an authorized public or private entity to assist
in disaster relief efforts and to coordinate uses and disclosures to
family or other individuals involved in your health care.
Emergencies: We may use or disclose your protected health
information in an emergency treatment situation. If this happens, your
physician shall try to obtain your acknowledgement of receipt of the
Notice of Privacy Practices as soon as reasonably practicable after the
delivery of treatment.
Permitted and Required Uses and Disclosures That May Be Made Without
Your Consent, Authorization or Opportunity to Object
We may use or disclose your
protected health information in the following situations without your
consent or authorization. These situations include:
By Law: We may use
or disclose your protected health information to the extent that law
requires the use or disclosure. The use or disclosure will be made in
compliance with the law and will be limited to the relevant requirements
of the law. You will be notified, as required by law, of any such uses
Health: We may
disclose your protected health information for public health activities
and purposes to a public health authority that is permitted by law to
collect or receive the information. The disclosure will be made for the
purpose of controlling disease, injury or disability. We may also
disclose your protected health information, if directed by the public
health authority, to a foreign government agency that is collaborating
with the public health authority.
Diseases: We may
disclose your protected health information, if authorized by law, to a
person who may have been exposed to a communicable disease or may
otherwise be at risk of contracting or spreading the disease or
Oversight: We may
disclose protected health information to a health oversight agency for
activities authorized by law, such as audits, investigations, and
inspections. Oversight agencies seeking this information include
government agencies that oversee the health care system, government
benefit programs, other government regulatory programs and civil rights
or Neglect: We may
disclose your protected health information to a public health authority
that is authorized by law to receive reports of child abuse or neglect.
In addition, we may disclose your protected health information if we
believe that you have been a victim of abuse, neglect or domestic
violence to the governmental entity or agency authorized to receive such
information. In this case, the disclosure will be made consistent with
the requirements of applicable federal and state laws.
and Drug Administration: We
may disclose your protected health information to a person or company
required by the Food and Drug Administration to report adverse events,
product defects or problems, biologic product deviations, track
products; to enable product recalls; to make repairs or replacements, or
to conduct post marketing surveillance, as required.
Proceedings: We may
disclose protected health information in the course of any judicial or
administrative proceeding, in response to an order of a court or
administrative tribunal (to the extent such disclosure is expressly
authorized), in certain conditions in response to a subpoena, discovery
request or other lawful process.
Enforcement: We may also
disclose protected health information, so long as applicable legal
requirements are met, for law enforcement purposes. These law
enforcement purposes include (1) legal processes and otherwise required
by law, (2) limited information requests for identification and location
purposes, (3) pertaining to victims of a crime, (4) suspicion that death
has occurred as a result of criminal conduct, (5) in the event that a
crime occurs on the premises of the practice, and (6) medical emergency
(not on the Practice’s premises) and it is likely that a crime has
Funeral Directors, and Organ Donation:
We may disclose protected health information to a coroner or medical
examiner for identification purposes, determining cause of death or for
the coroner or medical examiner to perform other duties authorized by
law. We may also disclose protected health information to a funeral
director, as authorized by law, in order to permit the funeral director
to carry out their duties. We may disclose such information in
reasonable anticipation of death. Protected health information may be
used and disclosed for cadaveric organ, eye or tissue donation purposes.
Compensation: we may disclose your protected health information as
authorized to comply with workers’ compensation laws and other similar
legally established programs.
Inmates: We may use or disclose your protected health
information if you are an inmate of a correctional facility and your
physician created or received your protected health information in the
course of providing care to you.
or Closure of the Practice: In the event that Donald D Berg MD PC is sold or
acquired by another facility or physician group, your protected health
information will be disclosed to that group or entity.
Uses and Disclosures:
Under the law, we must make disclosures to you and when required by the
Secretary of the Department of Health and Human Services to investigate
or determine our compliance with the requirements of Section 164.500 et.
Following is a statement of
your rights with respect to your protected health information and a
brief description of how you may exercise these rights.
have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of
protected health information about you that is contained in a designated
record set for as long as we maintain the protected health information.
A “designated record set” contains medical and billing records and
any other records that your physician and the practice use for making
decisions about you.
Under federal law, however,
you may not inspect or copy the following records; psychotherapy notes;
information compiled in reasonable anticipation of, or use in, a civil,
criminal, or administrative action or proceeding, and protected health
information that is subject to law that prohibits access to protected
health information. Depending on the circumstances, a decision to deny
access may be reviewed. In some circumstances, you may have a right to
have this decision reviewed. Please contact our Privacy Officer if you
have questions about access to your medical record.
have the right to request a restriction of your protected health
information. This means 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 for notification
purposes as described in this Notice of Privacy Practices. Your request
must state the specific restriction requested and to whom you want the
restriction to apply.
Your physician is not required
to agree to a restriction that you may request. If your physician
believes it is in your best interest to permit use and disclosure of
your protected health information, your protected health information
will not be restricted. If your physician does agree to the requested
restriction, we may not use or disclose your protected health
information in violation of that restriction unless it is needed to
provide emergency treatment. With this in mind, please discuss any
restriction you wish to request with your physician. You may request a
restriction by contacting and discussing the issue with the Privacy
have the right to request to receive confidential communications from us
by alternative means or at an alternative location. We will accommodate reasonable requests. We may
also condition this accommodation by asking you for information as to
how payment will be handled or specification of an alternative address
or other method of contact. We will not request an explanation from you
as to the basis for the request. Please make this request in writing to
our Privacy Officer.
may have the right to have your physician amend your protected health
means you may request an amendment of protected health information about
you in a designated record set for as long as we maintain this
information. In certain cases, we may deny your request for an
amendment. If we deny your request for amendment, you have the right to
file a statement of disagreement with us and we may prepare a rebuttal
to your statement and will provide you with a copy of any such rebuttal.
Please contact our Privacy Officer to determine if you have questions
about amending your medical record.
have the right to receive an accounting of certain disclosures we have
made, if any, of your protected health information. This right applies to disclosures for purposes
other than treatment, payment or healthcare operations as described in
this Notice of Privacy Practices. It excludes disclosures we may have
made to you, for a facility directory, to family members or friends
involved in your care, or for notification purposes. You have the right
to receive specific information regarding these disclosures that
occurred after April 14, 2003. You may request a shorter timeframe. The
right to receive this information is subject to certain exceptions,
restrictions and limitations.
will receive a paper copy of this notice from us, upon request, even if you have agreed to accept
this notice electronically.
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 of your complaint. We will not retaliate
against you for filing a complaint.
You may contact The Privacy Officer of Donald D Berg MD PC at 641-682-5443 for further information about the complaint process or on line at email at firstname.lastname@example.org.
This notice was published and becomes effective on April 14, 2003.
Last Updated: February 06, 2007