NOTICE OF PRIVACY PRACTICES
& SMS Terms of Service for
Olympas Medial Services LLC (dba Dr. Rotchford & OPAS)
This notice describes how medical information about you may be used and disclosed, as well as how to access it. Please review it carefully. The SMS Terms at the end allow us to text one another as described.
The offices of James K. Rotchford, M.D., and OMS LLC, doing business as OPAS, respect your privacy. We understand that your personal health information is sensitive. We will not disclose your information to others unless you have authorized us to do so or the law authorizes or requires us to do so.
The law protects the privacy of the health information we create and obtain when providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatments, health information from other providers, and billing and payment information relating to these services. Federal and state law allow us to use and disclose your protected health information for treatment and healthcare operations. State law requires us to get your authorization to disclose this information for payment purposes.
Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations:
Information obtained by a nurse, physician, or other member of our healthcare team will be recorded in your medical record and used to help you decide what care is best for you.
We may also provide information to others who are providing you with care. This will help them stay informed about your care.
For payment:
We request payment from your health insurance plan. Health plans need information from us about your medical care. Information provided to health plans may include your diagnoses, procedures performed, or recommended care.
For health care operations:
We use your medical records to evaluate the quality of our services and make improvements.
We may use and disclose medical records to review the qualifications and performance of our healthcare providers and train our staff.
We may contact you to remind you about appointments and give you information about treatment alternatives or other health-related benefits and services.
We may contact you to raise funds.
We may use and disclose your information to conduct or arrange for services, including:
Medical quality review by your health plan.
Accounting, legal, risk management, and insurance services. Page 1
Audit functions, including fraud and abuse detection and compliance programs.
Your Health Information Rights
The health and billing records we create and store are the property of the practice or healthcare facility. The protected health information in it, however, generally belongs to you. You have a right to:
Receive, read, and ask questions about this notice.
You may request that we restrict specific uses and disclosures of your health information. You must submit this request in writing. We are not required to grant the request, but we will comply with any request.
Request and receive a paper copy of the most current Notice of Privacy Practices for Protected Health Information (“Notice”).
You may request to see and get a copy of your protected health information in writing. We have a form available for this type of request.
Have us review a denial of access to your health information, except in certain circumstances.
We request that you update your health information. Please give us this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record and included with any release of your documents.
When you request it, we will provide you with a list of disclosures of your health information. The list does not include disclosures to third-party payers. You may receive this information without charge once every 12 months. We will notify you of the cost if you request it more than once within a 12-month period.
You can request that your health information be provided in an alternative format or at an alternative location. Please sign, date, and give us your request in writing.
You can cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released or any action taken before our receipt of it. However, sometimes, you cannot cancel an authorization if its purpose is to obtain insurance.
Our Responsibilities
We are required to:
Keep your protected health information private.
Give you this Notice.
Follow the terms of this Notice.
We have the right to change our practices regarding the protected health information we maintain. If we make any changes, we will update this Notice accordingly. You can obtain the most recent copy of this Notice by calling and requesting it, or by visiting our office or medical records department to pick one up.
To Ask for Help or Complain:
If you have questions, need more information, or wish to report a problem with handling your protected health information, please contact our office at (360) 385-4843.
If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to the person in charge at our practice or healthcare facility. You may also file a complaint with the U.S. Secretary of Health and Human Services. We respect your right to file a complaint with us or the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.
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Other Disclosures and Uses of Protected Health Information
Notification of Family and Others:
Unless you object, we may disclose your health information to a friend or family member who is involved in your medical care.
Those with substance use agreements give permission when professionally indicated. We may also provide information to someone who helps cover the costs of your care. We may tell your family or friends your overall condition and that you are in a hospital. Additionally, we may disclose health information about you to support disaster relief efforts. You have the right to object to this use or disclosure of your information. If you object, we will not use or disclose it unless you have already signed our substance use agreement.
We may use and disclose your protected health information without your authorization as follows:
With Medical Researchers—if the research has been approved and has policies to protect the privacy of your health information. We may also share information with medical researchers preparing to conduct a research project.
To Funeral Directors/Coroners, consistent with applicable law, to allow them to carry out their duties.
To organ procurement organizations (tissue donation and transplant) or persons who obtain stored or transplanted organs.
To the Food and Drug Administration (FDA) relating to problems with food, supplements, and products.
To Comply With Workers’ Compensation Laws, if you make a workers’ compensation claim.
For Public Health and Safety Purposes as Allowed or Required by Law:
To prevent or reduce a serious, immediate threat to the health or safety of a person or the public.
To public health or legal authorities.
To protect public health and safety.
To prevent or control disease, injury, or disability.
To report vital statistics such as births or deaths.
To Report Suspected Abuse or Neglect to the public authorities.
To Correctional Institutions, if you are in jail or prison, as necessary for your health and the health and safety of others.
For Law Enforcement Purposes, such as when we receive a subpoena, court order, or other legal process, or you are the victim of a crime.
For Health and Safety Oversight Activities, we may share health information with the Department of Health.
For Disaster Relief Purposes, we may share health information with disaster relief agencies to assist in notifying family or others of your condition.
For Work-Related Conditions That Could Affect Employee Health. For example, an employer may ask us to assess health risks on a job site.
To the Military Authorities of U.S. and Foreign Military Personnel. For example, the law may require us to provide information necessary for a military mission.
In the Course of Judicial/Administrative Proceedings at your request or as directed by a subpoena or court order.
For Specialized Government Functions. For example, we may share information for national security purposes.
Other Uses and Disclosures of Protected Health Information
Uses and disclosures not mentioned in this Notice will only be made as permitted or required by law, or with your written authorization. Page 3
SMS Terms of Service
You agree to receive SMS messages or secure email from Olympas Medical Services, LLC by opting into SMS from a web form or other medium. This includes SMS messages for appointment scheduling, appointment reminders, post-visit instructions, lab notifications, and billing notifications. Message frequency varies. Message and data rates may apply. See our privacy policy online at:
https://docs.google.com/document/d/1AXeyRAT9BpfKkoF6vUVbn390KHNsMro-PCq7qHJRPho/edit?usp=sharing.
Your personal information is collected and secured in accordance with HIPAA requirements, which are stringent and require formal approval for sharing outside of HIPAA-managed entities.
SMS consent and phone numbers are not shared with any third parties/affiliates for marketing purposes.
If you consent to receive SMS from Olympas Medical Services LLC, you agree to receive text messages from this office regarding appointments or indicated diagnostic interventions consistent with your care. Reply STOP to opt out; Reply HELP for support; Message & data rates may apply; Messaging frequency may vary.
⃣ Check if you consent to the SMS Terms of Service
ACKNOWLEDGEMENT—After reading this full notice of privacy practices, please sign it and, if applicable, return it to the office.
We keep a record of the healthcare services we provide to you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. Exceptions may apply if you are asked to sign a controlled substance agreement. You may see your record or get more information
by contacting us.
I acknowledge receipt of the Notice of Privacy Practices and if checked the SMS Terms of Service, and I agree to the terms of service by signing below.
_____________________________________________________
Patient's or legally authorized individual's printed name
_________________________________________ _____/____/____
Patient's or legally authorized individual's signature Date
This form is to be retained in your medical record. Page 4