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> Complete Privacy Statement
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Dallas ENT Head & Neck Surgery
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Notice of Privacy Practices
WHAT IS THIS NOTICE?
This notice tells you:
How we use and release your private health information (PHI)
Your rights concerning your private health information
Our responsibilities to protect your private health information
WHAT ARE OUR RESPONSIBILITIES TO YOU?
Your health information is personal. We are required by law to protect the privacy of your health information and will only release your health information as allowed by law or with special written authorization from you. We use the least amount of health information needed to do our work. Only those who need your health information to provide services are allowed to use it. We protect your information whether verbal, on paper or electronic. We will abide by the terms of this notice; notify you if we are unable to agree to a requested restriction. We will accommodate reasonable requests you may have regarding communication of PHI.
WHEN IS THIS NOTICE EFFECTIVE?
This notice becomes effective on April 14, 2003. We reserve the right to change this notice after the effective date. We reserve the right to make the revised notice apply for all PHI that we already have about you, as well as any information we receive in the future.
HOW DO WE USE AND RELEASE YOUR PRIVATE HEALTH INFORMATION?
We use and release necessary PHI to conduct business. The following section explains some of the ways we are permitted to use and release PHI without authorization from you.
USE AND RELEASE OF YOUR PHI WITHOUT YOUR AUTHORIZATION:
While we are providing you with healthcare services, we may need to share your PHI with other healthcare providers or other individuals who are involved in your treatment. Examples include: physicians, hospitals, pharmacists, therapists, nurses and labs that are involved in your care.
We may need to share a limited amount of PHI to obtain payment for the healthcare services provided to you. Examples include:
Eligibility - We may contact the company or government program that will be paying for your healthcare. This helps us determine if you are eligible for benefits, and if you are responsible for paying a co-payment or deductible.
Claims - We share PHI for billing and payment purposes with contracted companies. For example, the physician must submit a claim form to get paid and the claim must contain certain PHI.
Healthcare Operations Purposes
We may need to share your PHI in the course of conducting healthcare business activities that are related to providing health care to you. Examples include:
Quality Improvement Activities - We may use and release PHI to improve the quality or cost of care. This may include reviewing that treatment and services provided to you. This information may be shared with those who pay for your care or with other agencies that review this data.
Case Management and Referral - If you have a health problem or a health care need is identified by you or one of your providers, you may be referred to an organization such as a home health agency, medical equipment company or other community or government programs. This may require the release of your PHI.
Business Activities - We may use or release your PHI to perform internal business activities. Examples include: business planning, computer systems maintenance, legal services or customer service.
Required By Law - We may be required to report some of your PHI to legal officials or authorities, such as law enforcement officials, governmental agencies or attorneys. Examples include: reporting suspected abuse or neglect, reporting domestic violence or certain physical injuries, or responding to a court order, subpoena, warrant or lawsuit request.
Public Health Activities - We may be required to release PHI to authorities to help prevent or control disease, injury or disability. Examples include: reporting certain disease, injuries, birth or death information; information of concern to the FDA; or information related to abuse or neglect. We may also have to report to your employer certain work related illnesses and injuries so that your workplace can be monitored for safety.
Health Oversight Agencies - We may be required to release PHI to authorities so they can monitor, investigate, inspect, discipline or license whose who work in the healthcare system, or for governmental benefit programs.
Activities Related to Death - We may be required to release PHI to coroners, medical examiners and funeral directors so they can carry out their duties related to your death. Examples include: determining the cause of death, or, in the case of funeral directors, carrying out funeral preparation activities.
To Avoid a Serious Threat to Health or Safety - As required by law and standards of ethical conduct, we might release your PHI to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to anyone's health or safety.
Military, National Security or Incarceration/Law Enforcement Custody - We may be required to release your PHI to the proper authorities so they may carry out their duties under the law. This may be the case if you are in the military or involved in national security or intelligence activities, or if you are in the custody of law enforcement officials.
Workers' Compensation - We may be required to release your PHI to the appropriate persons to comply with the laws related to workers' compensation or other similar programs that provide benefits for work related injuries or illness.
USE AND RELEASE OF YOUR HEALTH INFORMATION REQUIRING YOUR AUTHORIZATION
Persons Involved in Your Care - In certain situations, we may release your PHI to persons involved with your care, such as friends or family members. We may also give information to someone who helps pay for your care. You have the right to approve such releases, unless you are unable to function, or if there is an emergency.
WHEN IS YOUR AUTHORIZATION REQUIRED?
Except for the types of situations listed above, we must obtain your authorization for any other types of releases of your PHI. If you provide us authorization to use or release PHI about you, you may cancel that authorization in writing at any time.
WHAT ARE YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION?
We want you to know your rights regarding your health information.
Right to Receive This Notice of Privacy Practices - You have the right to receive a paper copy of this notice at any time.
Right to Request Confidential Communication - You have the right to ask that we communicate your PHI to you by different means and places. For example, you can ask that we only contact you by telephone or work, or that we only contact you by mail at home. We will do this whenever it is reasonably possible. You can find out how to make such a request by contacting the privacy officer.
Right to Request Restrictions - You have the right to request restrictions or limitations on how your PHI is used or released. We are required to accommodate only reasonable requests. You may ask for a restriction on the use or release of your information by contacting the privacy officer. You may also request that we limit disclosure to family members, other relatives or close personal friends that may not be involved in your care.
Right to Access - With few exceptions, you have the right to review, by appointment, and receive a copy of your PHI. Some exceptions include: psychotherapy notes, information gathered for court proceedings, and any information your provider feels would cause you to commit serious harm to yourself or others.
You can get a copy of your PHI by submitting a request in writing to our office. We may charge you a fee to copy and/or mail your PHI to you. If you are denied access to your records for any reason, we will notify you of the reason(s) in writing.
Right to Amend - You have the right to ask that information in your health record be amended if it is not correct or complete. You must provide the reason why you are asking for the amendment. You may request an amendment by sending a request in writing to the office or at the time of your appointment to review your PHI with a member of our staff. We may deny the request if we did not create the information, we do not keep the information, or the information is already correct and complete. An amendment form is available in our office.
Right to a Record of Releases - You have the right to ask for a list of releases of your PHI by sending a request in writing to the privacy officer at this office. If you request a record of releases more than once per year, we may charge a fee for providing the list. The list will contain only information that is required by law. This list will not include releases for treatment, payment, healthcare operations or releases that you have authorized.
WHAT CAN YOU DO IF YOU HAVE A COMPLAINT ABOUT HOW YOUR HEALTH INFORMATION IS HANDLED?
If you believe that your privacy rights have been violated, you may contact the privacy officer listed below. You may also file a complaint with the Office for Civil Rights, US Department of Health and Human Services. There will be no retaliation for filing a complaint with either the privacy officer or with the Office for Civil Rights. The address for the Office of Civil Rights is listed below.
Dallas ENT & Allergy Center, PA
C/O Privacy Officer
221 West Colorado Blvd, Suite 943
Dallas, TX 75208
Office for Civil Rights
US Dept of Health & Human Svcs.
200 Independence Ave. SW
Room 509F, HHH Building
Washington DC, 20201