ATHOL, MA. 01331

September 23, 2013



At North Quabbin Family Physicians, P.C., we are committed to treating and using protected health information about you responsibly. This Notice of Privacy Practices (Notice) describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information (PHI). This Notice is effective 09/23/13, and applies to all PHI as defined by federal regulations.

Understanding Your Health Record/Information

Each time you visit North Quabbin Family Physicians, P.C., a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

Understanding what is in your record and how your PHI is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your PHI, and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your health record is the physical property of North Quabbin Family Physicians, P.C., the information belongs to you. You have the right to:

We are required to agree to requests for restrictions of certain disclosures to health plans for purposes of carrying out payment or health care operations (and not for purposes of carrying out treatment), except where otherwise required by law, when the information pertains solely to a healthcare item or service for which we have been paid out of pocket in full by you, or by a person on your behalf, other than the health plan.

Our Responsibilities

North Quabbin Family Physicians, P.C. is required to:

We reserve the right to change our practices and to make the new provisions effective for all PHI we maintain. Should our information practices change, we will make a new notice available upon request.  We will post a copy of the new notice at our practice in the waiting room and on our website at  Upon your request, will provide you with a copy of the notice in person, by mail or by email.  We will not use or disclose your PHI without your authorization, except as described in this Notice. We will also discontinue to use or disclose your PHI after we have received a written revocation of the authorization according to the procedures included in the authorization.

For More Information or to Report a Problem

If have questions and would like additional information, you may contact the practice's Privacy Officer, Nancy Holston by telephone at 978-249-2001 or by mail at 201 South Main Street, Athol, Ma.

If you believe your privacy rights have been violated, you can file a complaint with the practice's Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is listed below:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Uses and disclosures of your PHI 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 our practice has taken an action in reliance on the use or disclosure indicated in the authorization.

We must obtain your written authorization for uses and disclosures of medical information for marketing purposes and for disclosures of medical information that constitutes a sale of the information.

Uses and Disclosure of Health Information that do not Require your Authorization

The following describe different ways that we use and disclose PHI, without your written authorization for treatment, payment and healthcare operations purposes. 

We will use your PHI for treatment. We may use and disclose PHI about you to provide, coordinate or manage your healthcare and related services. This may include communicating with other healthcare providers regarding your treatment and coordinating and managing your healthcare with others. For example, we may use and disclose PHI about you when you need a prescription, lab work, and x-ray, or other healthcare services.

For example: Your doctor may share PHI about you with another healthcare provider. For example, if you are referred to another doctor, that doctor will need to know if you are allergic to medications. Similarly, your doctor may share PHI about you with a pharmacy when calling in a prescription.

We will use your PHI for payment. Generally, we may use and give your PHI to others to bill and collect payment for the treatment and services provided to you. Before your scheduled services, we may share PHI with your health plan(s). Sharing information allows us to ask for coverage under your plan or policy and for approval of payment before we provide the services. We may also share portions of your PHI with billing departments, collection departments, and consumer reporting agencies.

For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

We may use and disclose PHI in performing business activities, which we call "healthcare operations.” These healthcare operations allow us to improve the quality of care we provide and reduce healthcare costs.

For example: Members of the staff, may use PHI in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

We may use and disclose PHI without your authorization for a number of circumstance in which you do not have to consent, give authorization or otherwise have an opportunity to agree or object. Those circumstances include:

Business associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, and certain laboratory tests.  When these services are contracted, we may disclose your PHI to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your PHI, however, we require the business associate to appropriately safeguard your information.

Notification: We may use or disclose PHI to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

Communication with family: Health professionals, using their professional judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, PHI relevant to that person's involvement in your care or payment related to your care. We will not disclose routine type information to a spouse without your consent.

Funeral directors: We may disclose PHI to funeral directors consistent with applicable law to carry out their duties.

Organ procurement organizations: Consistent with applicable law, we may disclose PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Workers compensation: We may disclose PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Required or Permitted by Law, including Public Health Activities: As required by law, we may disclose your PHI when we are required or permitted to do so by federal, state or local laws, or required by a registry.  For example, we may disclose your PHI o the FDA, public health authorities charged with preventing or controlling disease, injury or disability, and to make required reports to government agencies.

Neglect/Abuse, Serious Threats to Health or Safety: To the extent required by law, we may disclose your PHI to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence.  We may disclose your PHI to the extent necessary to help avert a serious threat to your health or safety or the health or safety of others.   

Lawsuits and Legal Proceedings: If you are involved in a lawsuit or a legal proceeding, we may use and disclose your PHI in response to a court order.  We may use and disclose PHI about you in legal proceedings without your permission or a court order when you sue any of our health care providers or staff or practice for malpractice or initiate a complaint with a licensing board against any of our health care providers.

Law Enforcement: To the extent required by law, we may use and disclose PHI about you to correctional or law enforcement officials when necessary or appropriate, including in response to a court’s authority, such as a court order or search warrant, about a death required to be reported to a medical examiner, such as where we believe the death may be the result of violence or other suspicious or unusual circumstances, and in some circumstances, to report a crime, the location of the crime or victims or the identify, description or location of the person who may have committed the crime. 

National Security: We may disclose to military authorities PHI of Armed Forces personnel under certain circumstances.  We may disclose to authorized federal official health information required for lawful intelligence, counterintelligence, and other national security activities.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose, under certain circumstances, health information about you to the correctional institution or to the law enforcement officer if such officer represents that the health information is necessary to provide you with health care. 

Cell Phones: Our physicians may contact you by cell phone. Cell phone calls are not as secure as land-line calls and could be monitored. If you do not wish to be contacted via a cell phone you must inform our office or answering service when requesting a call back. This request could result in a delay in being called by the physician.