NOTICE
REGARDING PRIVACY OF PERSONAL HEALTH INFORMATION
For Family
Allergy and Asthma CARE
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.
Federal
regulations developed under the Health Insurance Portability and Accountability
Act (HIPAA) requires that the practice provide you with this Notice Regarding
Privacy of Personal Health Information. The Notice describes (1) how the
practice may use and disclose your protected health information, (2) your
rights to access and control your protected health information in certain
circumstances, and (3) the practices' duties and contact information.
1. Protected
Health Information
"Protected
health information" is health information created or received by your
health care provider that contains information that may be used to identify
you, such as demographic data. It includes written or oral health information
that relates to your past, present or future physical or mental health; the
provision of health care to you; and your past, present, or future payment for
health care.
II. The Use and
Disclosure of Protected Health Information in Treatment, Payment, and
Health Care Operations
Your
protected health information may be used and disclosed by the practice in the
course of providing treatment, obtaining payment for treatment, and conducting
health care operations. Any disclosures may be made in writing, electronically,
by facsimile, or orally. The practice may also use or disclose your protected
health information in other circumstances if you authorize the use or
disclosure, or if state law or the HIPAA privacy regulations authorize the use
or disclosure.
Treatment.
The practice may use and disclose your protected health information in
the course of providing or managing your health care as well as any related
services. For the purpose of treatment, the practice may coordinate your health
care with a third party. For example, the practice may disclose your protected
health information to a pharmacy to fulfill a prescription for asthma
medication, to an X-ray facility to order an X-ray, or to another physician who
is administering your allergy shots which we prepared. In addition, the
practice may disclose protected health information to other physicians or
health care providers for treatment activities of those other providers.
Payment.
When needed, the practice will use or disclose your protected health
information to obtain payment for its services. Such uses or disclosures may
include disclosures to your health insurer to get approval for a recommended
treatment or to determine whether you are eligible for benefits or whether a
particular service is covered under your health plan. When obtaining payment
for your health care, the practice may also disclose your protected health
information to your insurance company to demonstrate the medical necessity of
the care or for utilization review when required to do so by your insurance
company. Finally, the practice may also disclose your protected health
information to another provider where that provider is involved in your care
and requires the information to obtain payment.
Operations.
The practice may use or disclose your protected health information when
needed for the practice's health care operations for the purposes of management
or administration of the practice and of offering quality health care services.
Health care operations may include: (1) quality evaluations and improvement
activities; (2) employee review activities and training programs; (3)
accreditation, certification, licensing, or credentialing activities; (4)
reviews and audits such as compliance reviews, medical reviews, legal services,
and maintaining compliance programs; and (5) business management and general
administrative activities. For instance, the practice may use, as needed,
protected health information of patients to review their treatment course when
making quality assessments regarding allergy care or treatment. In addition,
the practice may disclose your protected health information to another provider
or health plan for their health care operations.
Other
Uses and Disclosures. As part of treatment, payment, and healthcare
operations, the practice may also use or disclose your protected health
information to: (1) remind you of an appointment; (2) inform you of potential
treatment alternatives or options; or (3) inform you of health-related benefits
or services that may be of interest to you.
11. Additional Uses and
Disclosures Permitted Without Authorization or An Opportunity to Object
In
addition to treatment, payment, and health care operations, the practice may
use or disclose your protected health information without your permission or
authorization in certain circumstances, including:
When
Legally Required.
The
practice will comply with any Federal, state or local law that requires it to
disclose your protected health information.
When
There Are Risks to Public Health.
The
practice may disclose your protected health information for public health
purposes, including to, as permitted or required by law:
(1) Prevent,
control, or report disease, injury, or disability;
(2) Report
vital events such as birth or death;
(3) Conduct
public health surveillance, investigations, and interventions;
(4) Collect
or report adverse events and product defects, track FDA regulated products,
enable product recalls, repairs, or replacements, and conduct post marketing
surveillance;
(5) Notify
a person who has been exposed to a communicable disease or who may be at risk
of contracting or spreading a disease; and
(6) Report
to an employer information about an individual who is a member of the
workforce.
To
Report Abuse, Neglect Or Domestic Violence.
As
required or authorized by law or with the patient's agreement, the practice may
inform government authorities if it is believed that a patient is the victim of
abuse, neglect or domestic violence.
To
Conduct Health Oversight Activities.
The
practice may disclose your protected health information to a health oversight
agency for use in (1) audits; (2) civil, administrative, or criminal
investigations, proceedings or actions; (3) inspections; (4) licensure or
disciplinary actions; or (5) other necessary oversight activities as permitted
by law. However, if you are the subject of an investigation, the practice will
not disclose protected health information that is not directly related to your
receipt of health care or public benefits.
For
Judicial And Administrative Proceedings.
The
practice may disclose your protected health information for any judicial or
administrative proceeding if the disclosure is expressly authorized by an order
of a court or administrative tribunal as expressly authorized by such order or
a signed authorization is provided.
For
Law Enforcement Purposes. The practice may disclose your protected
health information to a law enforcement official for law enforcement purposes
when:
(1) Required
by law to report of certain types of physical injuries;
(2) Required
by court order, court-ordered warrant, subpoena, summons or similar process;
(3) Needed
to identify or locate a suspect, fugitive, material witness or missing person;
(4) Needed
to report a crime in an emergency situation.
(5) You
are the victim of a crime in specific limited instances; and
(6) Your
death is suspected by the practice to be the result of criminal conduct.
To
Coroners, Funeral Directors, and for Organ Donation.
The
practice may disclose protected health information to a coroner or medical
examiner for the purpose of (1) identification, (2) determination of cause of
death, or (3) performance of the coroner or medical examiner's other duties as
authorized by law. In addition, as permitted by law, the practice may disclose
protected health information, including when death is reasonably anticipated,
to a funeral director to enable the funeral director to carry out his or her
duties. Protected health information may also be used and disclosed for the
purpose of cadaveric organ, eye or tissue donation.
For
Research Purposes.
The
practice may use or disclose your protected health information for research if
such use or disclosure has been approved by an institutional review board or
privacy board that has examined the research proposal and the research
protocols which maintain the privacy of your protected health information.
To
Prevent or Diminish A Serious and Imminent Threat To Health or Safety.
If
in good faith the practice believes that use or disclosure of your protected
health information is necessary to prevent or diminish a serious and imminent
threat to your health or safety or to the health and safety of the public, the
practice may use or disclose your protected health information as permitted
under law and consistent with ethical standards of conduct.
For
Specified Government Functions.
As
authorized by the HIPAA privacy regulations, the practice may use or disclose
your protected health information to facilitate specified government functions
relating to military and veterans activities, national security and
intelligence activities, protective services for the President and others,
medical suitability determinations, correctional institutions, and law
enforcement custodial situations.
For
Worker's Compensation.
The
practice may disclose your protected health information to comply with worker's
compensation laws or similar programs.
111. Uses and Disclosures Permitted
With An Opportunity to Object
Subject
to your objection, the practice may disclose your protected health
information
(1) to a family member or close personal friend if the disclosure is directly
relevant to the person's involvement in your care or payment related to your
care; or (2) when attempting to locate or notify family members or others
involved in your care to inform them of your location, condition or death. The
practice will inform you orally or in writing of such uses and disclosures of
your protected health information as well as provide you with an opportunity to
object in advance. Your agreement or objection to the uses and disclosures can
be oral or in writing. If you do not object to these disclosures, the practice
is able to infer from the circumstances that you do not object, or the practice
determines, in its professional judgment, that it is in your best interests for
the practice to disclose information that is directly relevant to the person's
involvement with your care, then the practice may disclose your protected
health information. If you are incapacitated or in an emergency situation, the
practice may exercise its professional judgment to determine if the disclosure
is in your best interests and, if such a determination is made, may only
disclose information directly relevant to your health care.
IV. Uses and Disclosures
Authorized by You
Other
than the circumstances described above, the practice will not disclose your
health information unless you provide written authorization. You may revoke
your authorization in writing at any time except to the extent that the
practice has taken action in reliance upon the authorization.
V.
Your Rights
You have
certain rights regarding your protected health information under the HIPAA
privacy regulations. These rights include:
The
right to inspect and copy your protected health information.
For as
long as the practice holds your protected health information, you may inspect
and obtain a copy of such information included in a designated record set. A
"designated record set" contains medical and billing records as well
as any other records that your physician and the practice uses to make
decisions regarding the services provided to you. The practice may deny your
request to inspect or copy your protected health information if the practice
determines in its professional judgment that the access requested is likely to
endanger your life or safety or that of another person, or that it is likely to
cause substantial harm to another person referred to in the information. You
have the right to request a review of this decision.
In
addition, you may not inspect or copy certain records by law, including: (1)
information compiled in reasonable anticipation of, or for use in, a civil,
criminal, or administrative action or proceeding; and (2) protected health
information that is subject to a law that prohibits access to protected health
information. You may have the right to have a decision to deny access reviewed
in some situations.
You must
submit a written request to the practice's Privacy Officer to inspect and copy
your health information. The practice may charge you a fee for the costs of
copying, mailing, or other costs incurred by the practice in complying with
your request. Please contact our Privacy Officer if you have questions about
access to your medical record at the number given on the last pages of this Notice.
The
right to request a restriction on uses and disclosures of your protected
health information.
You may
request that the practice not use or disclose specific sections of your
protected health information for the purposes of treatment, payment, or health
care operations. Additionally, you may request that the practice not disclose
your health information to family members or friends who may be involved in
your care or for notification purposes as described in this Notice. In your
request, you must specify the scope of restriction requested as well as the
individuals for which you want the restriction to apply. Your request should be
directed to the practice's Privacy Officer.
The
practice may chose to deny your request for a restriction, in which case the
practice will notify you of its decision. Once the practice agrees to the
requested restriction, the practice may not violate that restriction unless use
or disclosure of the relevant information is needed to provide emergency
treatment. The practice may terminate the agreement to a restriction in some
instances.
The
right to request to receive confidential communications from the practice by
alternative means or at an alternative location.
You have
the right to request that the practice communicates with you through
alternative means or at an alternative location. The practice will make every
effort to comply with reasonable requests. However, the practice may condition
its compliance by asking you for information regarding the procurement of
payment or specific information regarding an alternative address or other
method of contact. You are not required to provide an explanation for your
request. Requests should be made in writing to the practice's Privacy Officer.
The
right to request an amendment of your protected health information.
During
the time that the practice holds your protected health information, you may
request an amendment of your information in a designated record set. The
practice may deny your request in some instances. However, should the practice
deny your request for amendment, you have the right to file a statement of
disagreement with the practice. In turn, the practice may develop a rebuttal to
your statement. If it does so, the practice will provide you with a copy of the
rebuttal. Requests for amendment must be submitted in writing to the practice's
Privacy Officer. Your written request must supply a reason to support the
requested amendments.
The
right to request an accounting of certain disclosures.
You have
the right to request an accounting of the practice's disclosures of your
protected health information made for purposes other than treatment, payment or
health care operations as described in this Notice. The practice is not
required to account for disclosures (1) which you requested, (2) which you
authorized by signing an authorization form, (3) for a facility directory, (4)
to friends or family members involved in your care, and (5) certain other
disclosures the practice is permitted to make without your authorization. The
request for an accounting must be made in writing to our Privacy Officer and
should state the time period for which you wish the accounting to include up to
a six year period. The practice is not required to provide an accounting for
disclosures that take place prior to April 14, 2003. The practice will not
charge you for the first accounting you request of any 12-month period. Subsequent
accountings may require a fee based on the practice's reasonable costs for
compliance of the request.
The
right to obtain a paper copy of this Notice.
The
practice will provide a separate paper copy of this Notice upon request even if
you have already been given a copy of it or have agreed to review it
electronically.
VI. The Practice's
Duties
The
practice is required to ensure the privacy of your health information and to
provide you with this Notice of your rights and the practice's duties and
procedures regarding your privacy. The practice must abide by the terms of this
Notice, as may be amended periodically. The practice reserves the right to
change the terms of this Notice and to make the new Notice provisions effective
for all protected health information that the practice collects and maintains. If
the practice alters its Notice, the practice will provide a copy of the revised
Notice through regular mail or in-person contact.
VII. Complaints
If you
believe that your privacy rights have been violated, you have the right to
relate complaints to the practice and to the Secretary of the Department of
Health and Human Services. You may provide complaints to the practice verbally
or in writing. Such complaints should be directed to the practice's Privacy
Officer. The practice encourages you to relate any concerns you may have
regarding the privacy of your information and you will not be retaliated
against in any way for filing a complaint.
VIII. Contact
Person
The
practice's contact person regarding the practice's duties and your rights under
the HIPAA privacy regulations is the Privacy Officer. The Privacy Officer can
provide information regarding issues related to this Notice by request. Complaints
to the practice should be directed to the Privacy Officer at the following
address:
ATTN:
Privacy Officer
3051
Churchill Drive, #130
Flower
Mound, TX 75022
The
Privacy Officer can be contacted by telephone at
(972)
539-0086
This
Notice is effective on April 14, 2003.
PATIENT NAME: ________________________________________________
ACKNOWLEDGEMENT
OF ACCURACY
With my
signature, I affirm that all information, including insurance and subscriber
information, I have provided the staff of Family Allergy and Asthma Care is
accurate and as thorough as possible.
________________________________________ __________________
Signature
of Patient/Legal Guardian Date
RECEIPT
OF FINANCIAL POLICY
I have
received, read, and understand the Family Allergy and Asthma Care Patient’s
Bill of Rights and the Family Allergy and Asthma Care Financial Policy.
________________________________________ __________________
Signature
of Patient/Legal Guardian Date
RECEIPT
OF NOTICE REGARDING PRIVACY INFORMATION
I have
received, read, and understand the Family Allergy and Asthma Care Notice
Regarding Privacy of Personal Health Information.
________________________________________ __________________
Signature
of Patient/Legal Guardian Date
ASSIGNMENT
OF BENEFITS
I
authorize the assignment of any payment by my health insurance plan to my
physician.
________________________________________ __________________
Signature
of Patient/Legal Guardian Date
_______________________________________ __________________
Signature
of FAAC Staff Member Date