Notice of Privacy Practices
Effective January 2003
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read carefully.
Your Health Information & Rights
Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, and a plan for future care or treatment. This information is referred to as your health or medical record. This Notice of Privacy Practices described how we may use or disclose your health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.
Although your health record is the property of this practice, the information belongs to you. You have the right to:
1. Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522
2. Obtain a paper copy of this notice of privacy practices
3. Inspect and request a copy of your medical record as provided for in 45 CFR 164.524
4. Amend your health record as provided in 45 CFR 164.526
5. Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
6. Request communications of your health information by alternative means and locations
Bella Vita Medical Center’s Responsibilities:
1. Maintain the privacy of your health information
2. Provide you with this notice as to our legal duties and privacy practices with respect to your health information
3. Abide by the terms of this notice
4. Notify you if we are unable to agree to a requested restriction
We reserve the right to change our privacy practices and to make the new provisions effective for all protected health information we maintain. The current Notice of Privacy Practices can be reviewed by contacting us by calling and requesting that a revised copy be sent to you in the mail. We will not use or disclose your health information without your authorization, except as described in this notice.

For more information or to report a problem
If you have questions and would like additional information, you may contact the Center Manager for our practice by calling (615) 320 – 0900. If you believe that your privacy rights have been violated, you can file a complaint with the secretary of Health and Human Services. There will be no retaliation for filing a complaint.
Examples of Disclosures for Treatment, Payment and Health Care Operations:
Bella Vita Medical will use your health information for treatment. Your health information may be released to other healthcare professionals within the Center and the community for the purpose of providing you with quality healthcare. For example: Information obtained by one of our staff including physicians, nurses and administrative staff will be recorded in your record and used to determine the course of treatment that should work best for you. We will also provide your physician or a subsequent healthcare provider, such as a nursing home, home health care agency or physical therapy office, with copies of various reports that will assist them in treating outside of this office.
We will use your health information for payment. For example: A bill may be sent to your or a third party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, tests and supplies used in the course of your care in our office.
If you understand the above notice and information contained within, we ask that you sign and date that you acknowledge receipt of this information from our office. We will keep a copy of this signed notice in your medical record and provide you a copy for your own records. Thank you.
Disclosures
Business Associates: There are some services provided in our clinic through contracts with business associates. Examples include physician services in the emergency department and radiology, certain lab tests, transcription services and billing companies. Through a signed agreement, we require all business associates to comply with HIPAA laws and requirements to safeguard your health information.
Notification: We may use or disclose information to notify a family member, personal representative, or other person responsible for your care, your location and general condition.
Communication with family: Our staff, using their best judgment, may disclose to family member, other relative, close personal friend or any other person you identify, health information relevant to that persons involvement in your care or payment related to your care.
Food & Drug Administration: We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Workers Compensation: We may disclose health information to the extent authorized to comply with Tennessee laws relating to the workers compensation program.
Public Health: As required by Tennessee law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Communicable Disease: We may disclose health information as required by Tennessee law, to a person who may have been exposed to communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Abuse or Neglect: We may disclose health information to a health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the government agency authorized to receive such information.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Marketing & Patient Satisfaction Surveys: We may contact you to remind you of any appointments, healthcare treatment options or other health services that may be of interest to you. We may also contact you to obtain your opinion about our services.
Law Enforcement: we may disclose health information for law enforcement purposes as required by Tennessee law or in response to a valid subpoena or court order.
Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
Military & Veterans: If you are a member of the armed services, we may disclose health information as required by military command authorities.
More Stringent Laws
We will evaluate whether your protected health information is governed by more stringent laws or regulations prior to our use or disclosure. There are other more stringent laws and rules, such as the federal substance abuse confidentiality regulations, the TN Mental Health confidentiality statute(s), the TN Public Health confidentiality provisions, and state minor consent statute(s), governing status (i.e., emancipation, marital status, etc.) or type of treatment (abortion, sexually¬ transmitted disease, birth control, etc.), that may affect how we handle your information