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Premier Medical Group - Multispeciality Practice in Clarksville, Tennessee

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Privacy Policy

 Updated: August, 2015



This Notice describes how we may use or disclose your individually identifiable health information (protected health information or PHI) without an authorization. Not every use or disclosure in a category will be listed. Before making uses or disclosures not described below, we will ask for your written authorization. For example, we will not disclose psychotherapy notes, use or disclose your PHI for marketing purposes or sell your PHI unless you have signed an authorization or applicable law permits the use or disclosure. If you choose to sign an authorization permitting a use or disclosure of your PHI, you or your personal representative may later submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of PHI that occurred before you notified us of your decision to revoke your authorization.

1. Treatment

We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. We will disclose protected health information to other physicians who may be treating you, including your electronic health record exchanged with other physicians that you as the patient have been referred to, or have established a patient relationship. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you (e.g. specialists, hospital or laboratory), who at the request of your physician become involved in your care by providing assistance with your health care diagnosis or treatment.

2. Payment

Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility for benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Premier Medical Group may release all applicable medical information to all applicable insurance carriers, other third party payors, Social Security Administration, disability or Worker’s Compensation, or for other insurance purposes.

3. Healthcare Operations

We may use and disclose your PHI in performing a variety of business activities defined as “healthcare operations.” Examples:

  • Evaluating the skills and performance of healthcare providers taking care of you.
  • Employee review activities
  • Providing training programs for students, trainees, and health care providers.
  • Cooperating with outside organizations that evaluate, certify or license healthcare providers, staff or facilities.
  • Resolving complaints and establishing process improvements within our organization.
  • Arranging for legal services, budgeting and financial reporting.

Other Permitted and Required Uses and Disclosures (we may use or disclose your protected health information in the following situations without your consent or authorization)

  • Appointment Reminders
  • Use of sign in sheets
  • Calling your name in the waiting room
  • Leaving message reminders on a voicemail
  • Requesting a return call from you

4. Others Involved in Your Care

We may disclose medical information about you to a relative, close personal friend or any other person you identify if that person is involved in your care and the information is relevant to your care. If the patient is a minor, we may disclose medical information about the minor to a parent, guardian or other person responsible for the minor. If the patient is a minor, we may or may not be able to agree to your request. You may ask us at any time not to disclose medical information about you to persons involved in your care. We will agree to your request and not disclose the information except in certain limited circumstances (such as emergencies or disaster relief efforts). .

  • Emergencies – use and disclosure as determined by the healthcare provider
  • Required by Law – the use and disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law
  • Public Health – the disclosure will be made for the purpose of controlling disease, injury or disability, State of Tennessee Immunization Registry (past & current immunizations), including to foreign government agencies if applicable
  • Business Associates – we may disclose your PHI to individuals and entities that perform various jobs on our behalf (“Business Associates”), such as our billing company. Business Associates are required to safeguard your PHI.
  • Communicable Diseases – we may disclose your protected health information, if authorized by 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.
  • Health Oversight – we may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
  • Abuse or Neglect – we may disclose your PHI to the appropriate government authorities if we believe that abuse, neglect or domestic violence has occurred.
  • Food and Drug Administration – we may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls.
  • Legal Proceedings – we may use and disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court, a subpoena, a discover request or other lawful process.
  • Coroners, Funeral Directors, and Organ Donation – we may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cardiac organ, eye or tissue donation purposes.
  • Criminal Activity/Threats to Health and Safety– consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if its necessary for law enforcement authorities to identify or apprehend an individual.
  • Military Active and National Security Program – we may disclose PHI when requested by the armed forces for enlisted personnel, veterans, foreign military personnel, and national security and intelligence.
  • Worker’s Compensation and Occupational Medicine – we may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to work placement/employment or to evaluate whether you have a work-related illness or injury. We may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
  • Inmates – we may disclose PHI in certain circumstances for inmates in custody, as necessary for your health and the health and safety of other individuals.
  • Research – we may disclose your protected health 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 protected health information.
  • Other Uses and Disclosures – besides those identified in this Notice, uses and disclosures will be made only as otherwise required by law or with your written authorization and you may revoke the authorization.

Right to Revise Notice.

As permitted by law, we reserve the right to amend or modify this Notice and our privacy policies and practices. Upon request, we will provide you with the most recently revised Notice on any office visit. The revised Notice and policies and practices will be applied to all PHI we maintain.




  • Request a restriction on certain uses and disclosures of your health information by delivering the request to our office. We are not required to grant the request, except for disclosures to a health plan when you have paid in full out-of-pocket for your care.
  • Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information (Notice) by making a request to our office (even if you have previously agreed to receive this Notice electronically).
  • Request that you be allowed to inspect and copy your health record and billing record – you may exercise this right by delivering the request in writing to our office. We may charge a fee for the costs of copying, mailing or other supplies or services associated with your request.
  • Request that your health care record be amended to correct incomplete or incorrect information by delivering a request to our office in writing. We may deny your request if the PHI is already correct or for certain other reasons permitted by law.
  • Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office.
  • Obtain an accounting of disclosures (that have been made within the last 6 years) of your health information as required to be maintained by law by delivering a request to our office. An accounting will not include disclosures we are not required by law to record such as disclosures made pursuant to an authorization. The first list you request within a 12-month period is free, but we may charge a fee for any additional lists that you request. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

We are required by law to protect the privacy of medical information and provide Notice of our legal duties and privacy practices.


If you believe your privacy rights have been violated, you may file a written complaint either with us or the federal government. We will not take any action against you or change our treatment of you in any way if you file a complaint. To file a written complaint with us, please bring your complaint directly to our Privacy Officer, or you may mail it to us at the address on the front of this Notice.


To file a written complaint with the federal government, please use the following contact information:

Office for Civil Rights, DHHS

61 Forsyth Street SW – Ste 3B70

Atlanta GA 30303-8909

Phone: (404) 562-7886

TDD: (404) 331-2867

FAX: (404) 562-7881



You will not be penalized or otherwise retaliated against for filing a complaint. If we discover a breach by us involving your unsecured PHI, we will notify you of the breach by letter or other method permitted by law.

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