Notice of Privacy Practices

Effective 9/21/21 Revised 9/16/21

The Health Insurance Portability Act of 1996 (HIPAA) protects the confidentiality of medical records and other personal health information. The rule limits the use and release of individually identifiable health information; gives patients the right to access their medical records; restricts most disclosure of health information to the minimum needed for the intended purpose; and establishes safeguards and restrictions regarding the disclosure of records for certain public responsibilities, such as public health, research and law enforcement. Improper uses or disclosures under the rule are subject to criminal and civil sanctions prescribed in HIPAA.

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.

Fountain Point Imaging Center, LLC collects health information from you, and stores it in a chart and on a computer. This is a medical record. The medical record is the property of the Fountain Point Imaging Center, LLC but the information in the medical record belongs to you. Fountain Point Imaging Center, LLC protects the privacy of your health information. The law permits Fountain Point Imaging Center, LLC to use or disclose your health information for the following authorized purposes:

• Coordinating a treatment plan – e.g. to have prescriptions filled
• Payment for services – e.g. to bill your health plan
• Evaluating the quality of care you receive – e.g. to evaluate staff performances which may include conducting training programs in which students, trainees or practitioners in areas of health care learn under supervision to practice or improve their skills. This may also include students evaluating health career options.
• Research – e.g. effects of medication on the healing process
• Public Health – e.g. to prevent or control disease, injury or disability
• Health Oversight Activities – e.g. to allow the government to monitor the health care system, government programs, and compliance with civil rights laws
• Organ and Tissue Donation – e.g. to release information to organizations that handle organ procurement
• Law Enforcement – e.g. to identify or locate a suspect, fugitive, material witness or missing person
• Emergencies – e.g. to avert a serious threat to the health and safety of you, another person or the public
• Inmates – e.g. for the correctional institution to protect your health and safety
• Marketing and Fundraising – e.g. to send you information about products or services that we believe may be beneficial to you or to contact you for fundraising activities supported by our office. You may contact our Security Officer to request that these materials not be sent to you.

We are required by law to provide medical information that is court ordered and or requested by law enforcement officials. We may disclose your protected health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services. We will disclose only the minimum necessary amount of personal health information need to accomplish the contracted duties. All of our business associates are obligated under contract with us to protect the privacy of your information and are not allowed to use or disclose any information other than in a manner that would be permissible by Fountain Point Imaging Center, LLC to do so. No other uses or disclosures, except explicitly listed in the Notice of Privacy practices, may be made without an individual authorization. You have the right to revoke such an authorization in writing and we will honor your request, except under uncontrollable circumstances in which we acted upon your initial authorization.

Individual Rights

You have the right to:

• Request to inspect and/or copy your health records.
• Request an accounting of disclosure of health records.
• Request to amend your health records.
• Request restrictions on certain uses and disclosures or the manner or method of protected health care information. The Clinic is not required to honor a requested restriction.
• Receive confidential communications of protected health care information under certain circumstances.
• File complaints regarding privacy practices and/or unauthorized disclosure of protected health care information.
• Be notified of an unauthorized disclosure that compromises the privacy of your protected health care information.
• Require a health care provider to withhold any health plan/in-surer information pertaining to a treatment that the individual paid for out of pocket. It is the patient’s responsibility to notify Fountain Point Imaging Center, LLC in advance when they wish for this to be done.
• Maintain the confidentiality of your genetic information. We may not disclose any genetic information for insurance underwriting purposes.
• Request a written copy of the health care organization’s privacy practices.

Complaints

If you are concerned that we have violated your privacy rights, and or would like to express a concern regarding our privacy practices, you may report your complaint in writing to our Security Office at the address listed below. Please ask for the Security Officer for assistance in filing a complaint.

Security Officer

Fountain Point Imaging Center, LLC
3901 W. Norfolk Ave. Suite R
Norfolk, NE 68701
(402) 379-2349

You may also send a written complaint to the U.S. Department of Health and Human Services at the following address:

The U.S. Department of Health and Human Services Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll Free 1-877-696-6775

We will not retaliate against you for filing a complaint.

Our Legal Duty

We are required by law to protect the privacy of your information, provide this notice about our practices and to follow the guidelines described in this notice.

We reserve the right to change our policies at any time. If a significant change is made to our policy, it will be posted immediately in a conspicuous place in the imaging center.