THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Privacy Officer develops the Privacy Notice

The FMCNA Privacy Officer, in consultation with the Law Department, as necessary, will prepare and make the Privacy Notice available to the Company’s physical service delivery sites and appropriate covered functions. 

Covered functions abide by the Privacy Notice

Each Company function will abide by the terms of the Privacy Notice.

Provision of the Privacy Notice

Company will:

  • Offer a hard copy of the Privacy Notice to each patient who is receiving direct care from a Provider at an urgent care center upon the patient’s request, and 
  • Undertake good faith efforts to obtain each patient’s written acknowledgment of receipt of the Privacy Notice.

When patients receive Privacy Notice

Company will offer a copy of the Privacy Notice on the date of the patient’s first treatment, or, in emergency situations, as soon as reasonably practicable after the emergency situation.

Patient written Acknowledgment Form

Except in an emergency treatment situation, each time a Company center furnishes the Privacy Notice to a patient, it will make a good faith effort to obtain the patient’s written acknowledgement of receipt of the Privacy Notice from the patient.

A “good faith effort” to obtain patient acknowledgment shall consist of a teammate:

  • Presenting to the patient a Notice of Privacy Practices Acknowledgment of Receipt form, which contains an acknowledgment that the patient has received the Privacy Notice, and
  • Asking the patient to sign the Acknowledgment of NPP Form.

If the patient does not sign the form, the teammate will:

  • Write the reason for failing to obtain the patient’s signature on the copy of the Acknowledgment of NPP form that was provided to the patient, and
  • Sign and date the Acknowledgment of NPP Form.

Retention of Acknowledgment of NPP Forms

Company will retain the Acknowledgment of NPP Form, signed by the patient or teammate, in the patient’s medical record. 

Service delivery sites post the Privacy Notice

Each Company physical service delivery site will post the Privacy Notice in a clear and prominent location, where it is reasonable to expect that patients seeking service at such sites will be able to read the Privacy Notice.

Service delivery sites provide hard copies

Each Company physical service delivery site will have hard copies of the Privacy Notice available so that a patient may take a copy with him/her upon request.

Electronic access to Privacy Notice

Company will prominently post the Privacy Notice on the external Company website and make it available electronically.  

 Annual review of Privacy Notice

The FMCNA Privacy Officer will review the Privacy Notice on an annual basis, or more often as necessary to reflect changes in the HIPAA Privacy Rule, other applicable law, or changes in the uses or disclosures of Protected Health Information (PHI) by Company.

Posting Privacy Notice revisions

All changes and modifications of the Privacy Notice will be posted and made available to patients as required under this procedure.  

Specifically, whenever Company revises the Privacy Notice, Company will:

  • Post the revised Privacy Notice at each Company physical service delivery site;
  • Post the revised Privacy Notice on the external website;
  • Make the revised Privacy Notice available to patients on request. 

Note: Company is not required to deliver the revised Privacy Notice to its patients.

Privacy Officer maintains a copy of the Privacy Notice

FMCNA’s Privacy Officer will maintain a copy of all Privacy Notices that Company has issued.