Notice of Privacy Practices

Peterson Laboratory Services, P.A.

Notice of Privacy Practices for Protected Health Information

Effective Date: April 14, 2003

Updated from PCL to PLS April 21, 2005


This statement is being updated on April 21, 2005 to reflect the name change to Peterson Laboratory Services, P.A. (PLS)

Peterson Laboratory Services, P.A. (PLS) is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information (PHI) is the information we create and obtain in providing our services to you. Such information may include documenting your diagnosis and test results that may be used by your health care provider for future care or treatment. It also includes billing documents for those services.

Examples of Your Health Information Used for Treatment Purposes:

Patient presents to PLS with requisition from referring physician/authorized individual

PLS obtains billing information from Patient

PLS personnel may ask pertinent health information to provide referring physician/authorized individual appropriate information for interpretation

Results sent to referring physician/authorized individual and/or other entity at request of physician/authorized individual

Your physician determines he/she will need to consult with another specialist in the area. He/she may ask us to provide test results or other diagnostic information to such specialist

Examples of Your Health Information Used for Payment Purposes:

We submit requests for payment to your health insurance company based on

information on requisition provided by referring physician/authorized individual

Verbal, written or copied information provided by patient

Remittance advice from insurance company
Example of Your Information Used for Health Care Operations:

Patient insurance information will be shared with the appropriate entity for us to receive payment for services provided.
Your Health Information Rights

The health and billing records we maintain are the physical property of Peterson Laboratory Services, P.A. You have a right to:

Request a restriction on certain uses and disclosures of your health information. To do this, we need a written request. We will inform you about the status of the request.

Be given a paper copy of the current Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our office.

Request through your physician that you be allowed to inspect and obtain a copy of your test results – you may exercise this right by delivering your physician’s request to our office or by having the physician contact PLS.

Request that you be allowed to inspect and obtain a copy of your billing record – you may exercise this right by a written or verbal request to our office.

Request that your health care record be amended to correct incomplete or incorrect demographic information by delivering a request to our office. We may deny your request if you ask us to amend information that was not created by us, is not part of the health information kept by or for the laboratory; is not part of the information that you would be permitted to inspect and copy; or, is accurate and complete.

If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records;

You have the right to change or revoke any previous request made for PHI

If you want to exercise any of the above rights, please contact the Privacy Officer of Peterson Laboratory Services, P.A., 1133 College Ave, Bldg B, Manhattan, KS 66502; 785-539-5363 in person or in writing, during regular, business hours. He/she will inform you of the steps that need to be taken to exercise your rights.

Our Responsibilities

Peterson Laboratory Services, P.A. will:

Maintain the privacy of your health information as required by law;

Provide you with a notice of our duties and privacy practices pertaining to the information we collect and maintain about you;

Abide by the terms of this Notice;

Notify you if we cannot accommodate a requested restriction or request; and,

Accommodate your reasonable requests regarding methods to communicate health information with you. We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You will receive a revised copy of the Notice at your next visit or you may request a copy of our “Notice” by calling us or by visiting our office and picking up a copy.


If we maintain a website with a customer service function, we will post this Notice of Privacy Practices.

Documentation and Retention

PLS will retain copies of all Notice of Privacy Practices issued for a period of six years as set forth in 45 CFR 164.530(j).

Changes To This Notice

We reserve the right to change this notice without prior notification. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at Peterson Laboratory Services, P.A. The notice will contain the effective date on the first page.


You will be asked to provide a written acknowledgement of your receipt of this Notice of Privacy Practices.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the Privacy Officer at 785-539-5363.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to the Privacy Officer. You may also file a complaint by mailing it to the Secretary of Health and Human Services. U.S. Department of Health and Human Services; 200 Independence Avenue, S.W.; Washington, D.C. 20201.

We will not require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of providing laboratory services.

We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Other Disclosures and Uses


Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about general condition, or your death.

Communication with Family

Using our best judgment, and in the best interest of the patient, we may disclose health information to a family member, other relative, close personal friend, or any other person you identify as involved in your care or in payment for such care unless you file a specific restriction.

Food and Drug Administration (FDA)

We may disclose to the FDA your protected health information relating to adverse events with respect to products or post-marketing surveillance information to enable product recalls.

Workers Compensation

If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health

As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.

Abuse & Neglect

We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.


Except in cases involving workers' compensation, disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.

Correctional Institutions

If you are an inmate of a correctional institution, we may disclose the protected health information necessary for your health and the health and safety of other individuals to the institution or its agents

Law Enforcement

We may disclose your protected health information for law enforcement purposes as required by law, as required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.

Health Oversight

Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings

We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.

Serious Threat

To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions

We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Coroners, Medical Examiners, and Funeral Directors

We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary for them to carry out their duties.

Other Uses

Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under "Your Health Information Rights."