Understanding Your Health Information Rights

What is a health information record?

Each time you visit a healthcare practitioner (such as a doctor, dentist, nutritionist, acupuncturist, chiropractor, massage therapist, etc.), hospital or clinic, a record of your visit is made. Typically, this medical “record” or chart will contain information about your symptoms, examinations, lab test results, diagnosis, treatments and a plan for future care or treatment. Your medical record can be used in the following ways and serves as a:

• basis for planning your care and treatment;
• communication tool among the team of healthcare professionals involved in your medical care;
• means by which you or a third party payer (e.g. your health insurance company) can verify that services billed were actually provided;
• legal document describing the medical care you have received; and a tool for educating health professionals in training.

Why should I care what is in my medical record or who I authorize to disclose this information to?

The Health Insurance Portability and Accountability Act (HIPAA), passed by Congress in 1996, became effective in April 2003. Privacy and security standards promote higher quality care by assuring consumers that their health information will be protected from inappropriate uses and disclosures. 

Understanding what is contained in your medical record and how this health information can be used legally will help you:

• ensure that your medical record is accurate
• better understand why others may need to access your health information
• make more informed decisions about who you should authorize to receive your health information

 What Are Your Health Information Rights?

 Your health/medical record and information is the physical property of the healthcare professional or facility that compiled it but the information really belongs to you. According to privacy laws, you have the right to:

• request a restriction on certain uses and disclosures of your information.
• obtain a paper copy of the notice of information practices you request.
• inspect and copy your health/medical record.
• amend your health record.
• obtain an accounting of your health information disclosures to others.
• request communication of your health information by alternative means (fax, secure email, etc.) or at alternative locations outside of my office.
• limit your authorization to use or disclose health information except to the extent to which action has already been taken.

My Responsibility as Your Healthcare Provider

As your healthcare provider, I am required by law to:

• maintain the privacy of your health information
• provide you with this notice as to my legal duties and privacy policies with respect to the information I collect and maintain in your medical record
• abide by the terms of this notice
• notify you if I am not able to agree to a requested restriction
• accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations outside my office

I reserve the right to change my practices and to make the new provisions effective for all protected health information that is my responsibility to maintain on your behalf. Should my information practices change, I will mail a revised notice to you at the address you have provided.

I will not use or disclose any of your health information without your authorization, except as described in this notice.

Examples of Information That Can Be Disclosed for Your Healthcare Treatment, Payment and Health Operations

I will use your health information for treatment. For example: Information obtained from you at our first visit will be recorded in your medical record that I create. This information will be used for nutrition assessment and to create a nutrition care plan (NCP) with goals and actions to determine the course of treatment that should work best for you. Your physician or other healthcare team provider may request a copy of your nutrition assessment and nutrition care plan or I may choose to provide this information to your physician or other healthcare provider with your permission. 

I will use your health information for payment. For example: A bill may be sent to you or to a third- party payer such as your health insurance company. Information sent to a third-party payer will include your name, date of birth, insurance ID number, and diagnosis or reason for the visit. Information sent to you for payment will include your identifying information such as name and billing address along with the date of visit, charge for the visit and nutrition assessment CPT codes – such as 97802 for a first nutrition visit and 97803 for follow-up nutrition visits.

Other Uses or Disclosures

Business Associates

I contract with a health insurance billing company to process health insurance claims on behalf of my clients. To process your health insurance claim, it is necessary to provide the company with your name, date of birth, address, insurance ID number, diagnosis or reason for visit and the time unit for the visit. So that your health information is protected, I require the health insurance billing company to appropriately safeguard your information too.

Communication with Family Members, Partner or Personal Representative

I may use or disclose information to notify or assist in notifying a family member, partner, personal representative or another person responsible for your care, any relevant health information so the person involved in your care will know what to do on your behalf related to nutrition support and intervention. This information may also be needed to receive payment for nutrition services performed on your behalf. You have provided an emergency contact and telephone number that I will use for this purpose. Please notify me if this information should change.

Food and Drug Administration (FDA) and Public Health

I may disclose to the FDA only health information relevant to adverse effects related to food, nutrition supplements, functional foods and beverages that you may experience or in the event of a recall of any of these products that you may be using. Public Health officials charged with preventing and controlling disease, injury or disability are required by law to obtain relevant health information in the interest of public safety. I am required by law to disclose any health information related to this issue but would notify you first.

If you have questions or would like additional information, you may contact me for further information and resources at 206-920-7676.

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