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Frequently Used Forms

PRIVACY POLICY

NOTICE OF PRIVACY PRACTICES
IRVING PEDIATRICS

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.

We are required by law to protect the privacy of medical information about you and that identifies
you. This medical information may be information about health care we provide to you or payment for
the health care provided to you. It may also be information about your past present or future medical
condition. We are also required by law to provide you with these Notice of Privacy Practices explaining
our legal duties and privacy practices with respect to medical information. We are legally required to
follow the terms of this Notice. In other words, we are only allowed to use and disclose medical
information in the manner that we have described in this notice. We may change the terms of this Notice
in the future. We reserve the right to make changes and to make new Notices effective for all medical
information that we maintain. If we make changes to the notice, we will post the new Notice in a waiting
area and make copies of the new Notice available upon request. If at any time you have any questions
about information in this Notice or about our privacy policies, procedures, or practices, you can contact
our office.

We use and disclose medical information about patients every day. We may use and disclose this
information about you to provide you with healthcare, obtain payment for the care, and operate our
business efficiently. Medical information includes information about your illness, treatment, and
condition as well as information about where we can contact you, your social security number, and other
information necessary for the above activities. The following summarizes some of the most common uses
we have for your medical and other protected health information.

Uses and Disclosure for Treatment, Payment, and Health Care Operations

1. Treatment. We will use and disclose medical information about you to provide health care
treatment to you. This includes communicating with other health care providers regarding your
treatment. These other health care providers may or may not be our employees. Examples: Your
medical information may be needed to obtain authorization from your insurance company to
schedule your appointment. A lab technician may use medical information to process and review
test results. Medical information may be shared with physicians, radiologists, and other allied
healthcare professionals to make sure you receive the highest quality of care. If you receive
certain devices, such as pacemakers, hip replacements, or other implants, information about you
is given to the manufacturer for tracking product expiration, recalls, etc.

2. Payment. We will use and disclose medical information about you to obtain payment for the
health care services that you receive. This will include your insurance company and may include
a collection of agency and consumer reporting agencies. In some instances, we may disclose
medical information about you to an insurance plan before you receive health care services
because, for example, we may need to know whether your insurance plan will pay for a particular
service.

Examples: Certain services, for example, mammograms, are covered only once per year. This is
date specific and we need to verify your eligibility based on the last date you received the service.
Your insurance company may request a copy of your medical record to verify that all the services
we provided were necessary for your treatment. In addition, the bill we provide your insurance
company has medical information in it.

3. Health care operations. We may use and disclose medical information about you in performing a
variety of business activities that we call “health care operations”. These activities allow us to, for
example, improve the quality of care we provide and reduce health care costs. For example, we
may use or disclose medical information about you in performing the following activities:

     a. Reviewing and evaluating the skills, qualifications, and performance of the health care provider taking               care of you.
     b. Providing training programs for students, trainees, health care providers, or non-healthcare
     professionals to help them practice or improve their skills.
     c. Cooperating with outside organizations that evaluate, certify, or license our facility.
     d. Reviewing and improving the quality, efficiency, and cost of care.
     e. Improving healthcare and lowering costs for a group of people who have similar health
     problems and helping manage and coordinate the care for these groups of people.
     f. Planning for our organization’s future operations.
     g. Resolving grievances within our organization.
     h. Reviewing our activities and using or disclosing medical information in the event that control
     of our organization significantly changes.
     i. Working with others (such as lawyers, accountants, consultants, and other providers) who
     assist us in complying with this Notice and other laws.
     j. Our medical committees, such as the pharmacy committee, may review your medical
     information, in connection with other patients receiving the same treatment as you, to
     determine the effectiveness of our protocol. If you have a complaint about the care you
     receive, the appropriate individuals within our organization may review your medical
     information in order to evaluate the quality of care that you received. We may also disclose
     your health information to third parties with whom we contract to perform services on our behalf.

The rest of this Notice will discuss how we may use and disclose medical information about you;
explain your rights with respect to medical information about you; describe how and where you may file
a privacy-related complaint.

Other Uses and Disclosures for Which Authorization is Not Required.

Required by law. We will use and disclose medical information about you whenever we are required by
law to do so. There are many state and federal laws that require us to use and disclose medical
information. Examples: State law requires us to report gunshot wound(s) to the police, highly contagious
diseases such as sexually transmitted diseases and tuberculosis, and other test results to the Alabama
Department of Public Health and to report known or suspected child abuse or neglect to the Department
of Social Services. We are also required to maintain various registries (e.g. cancer, trauma) for the State
of Alabama.

National priority uses and disclosures. When permitted by law, we may use or disclose medical
information about you without your permission for various activities that are recognized as “national
priorities”. In these instances, the government has determined that it is so important to disclose medical
information and that it is acceptable to disclose medical information without the individual permission.
We will only disclose medical information about you in the following circumstances when we are
permitted to do so by law.

Below are brief descriptions of the national priority activities recognized by law.

Threat to health or safety. We may use or disclose medical information about you if we believe it
is necessary to prevent or lessen a serious threat to your health or safety.

Public Health Activities. We may use or disclose medical information about you for public health
activities. Public health activities require the use of medical information for various activities,
including, but not limited to, activities related to investigating diseases, reporting child abuse and neglect, monitoring drugs or devices regulated by the Food and Drug Administration, and
monitoring work-related illnesses or injuries. For example, if you have been exposed to a
communicable disease (such as a sexually transmitted disease) *, we may report it to the State
and take other actions to prevent the spread of the disease.

Research organizations. We may use or disclose medical information about you to research
organizations if the organization has satisfied certain conditions about protecting the privacy of
medical information.

Appointment reminders. We may use and/or disclose medical information about you to send you
reminders about an appointment.

Abuse, neglect, or domestic violence. We may disclose medical information about you to a
government authority (such as the Department of Social Services) if you are an adult and we
reasonably believe that you may be a victim of abuse, neglect, or domestic violence.

Health oversight activities. We may disclose medical information about you to a health oversight
agency – which is basically an agency responsible for overseeing the health care system or certain
government programs. For example, a government agency may request information from us
while they are investigating possible insurance fraud.

Court proceedings. We may disclose medical information about you to a court or an officer of the court (such as an attorney). For example, we would disclose medical information about you to a
court if a judge orders us to do so.

Law enforcement. We may disclose medical information about you to a law enforcement official
for specific law enforcement purposes. For example, we may disclose limited medical information
about you to a police officer if the officer needs the information to help find or identify a missing
person.

Coroners and others. We may disclose medical information about you to a coroner, medical
examiner, or funeral director or to organizations that help with organ, eye, and tissue transplants.

Workers’ compensation. We may disclose medical information about you in order to comply with
workers’ compensation laws.

Certain government functionality. We may use or disclose medical information about you for
certain governmental functions, including but not limited to military and veterans’ activities and
national security and intelligence activities. We may also use or disclose medical information
about you to a correctional institution in some instances.

Treatment alternatives. We may use and/or disclose medical information about you in order to
inform you of or recommend new treatment or different methods for treating a medical condition
that you have or to inform you of other health-related benefits and services that may be of
interest to you. Examples. you are a patient newly diagnosed with diabetes. we have developed
an educational program to help diabetes patients manage their diets. We may send you an
informational flyer about the program. Alternately, you may need a referral to a home health
agency, we have a program or hospice. information about you will be shared with these other
service providers.

Uses and Disclosures That May Be Made With Your Agreement or Opportunity to Object.

Hospital patient directory. We may use your name, your room number, your condition, and your religious
affiliation to maintain a patient directory. we made disclose this information to visitors who ask for you
by name and to members of the clergy. You have the right to opt out of this directory. To opt-out of this
directory alert the admissions clerk when you are registering or the Privacy and Security Officer During
your visit.

Persons 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, such as a disaster relief organization (e.g. Red Cross) If we need to notify someone
about your location or condition. You may ask us at any time not to disclose medical information about
you to persons involved in your care. If the patient is a minor, we may disclose medical information about
the minor to a parent, guardian, or other responsible for the minor except in limited circumstances. we
will agree to your request except in certain limited circumstances (such as emergencies) or if the patient
is a minor. If the patient is a minor, we may or may not be able to agree to your request. Example. your
spouse or parent may be present in your room When your medical information is discussed. you have the
right to ask to have your medical information discussed with you in private.

Uses and Disclosures of PHI for Which Authorization is Required.

Authorization. Other than the uses and disclosures described above, we will not use or disclose medical
information about you without the authorization (signed permission) of you or your personal
representative. In some instances, we may wish to use our disclosed medical information about you, and
we may contact you to ask you to sign an authorization form. In other instances, you may contact us to
ask us to disclose medical information, and we will ask you to sign an authorization form.

Revocation. if you sign a written authorization allowing us to disclose medical information about you, you
may later revoke (or cancel) your authorization in writing (except in very limited circumstances related to
obtaining insurance coverage). If you would like to revoke your authorization, you may write us a letter
revoking your authorization sorry fill out an Authorization Revocation Form. If you revoke your
authorization, we will follow your instructions except to the extent that we have already relied upon your
authorization and taken some action.

Regulatory Requirements. We are required by law to maintain the privacy of your Protected Health
Information (PHI), to provide individuals with notice of its legal duties and privacy practices with respect
to PHI, and to abide by the terms described in this notice which is currently in effect. we reserve the right
to change the terms of this notice and its privacy policies and to make the new terms applicable to the
entire PHI it maintains.

Individual Rights. You have several rights with respect to medical information about you. This section of
the notice will briefly mention each of these rights. if you would like to know more about your rights,
please contact our office.

Right to a copy of this notice. You have a right to have a paper copy of our Notice of Privacy
Practices at any time.

Right of access to inspect and copy. You have the right to see or review and receive a copy of
medical information how about you that we maintain certain sets of records. If you would like to
inspect or receive a copy of medical information about you, you must provide us with a request
in writing. You may write us a letter requesting access or fill out a Release of Information Form.
We may deny your request in certain circumstances. If we deny your request, we will explain our
reason for doing so in writing. We will also inform you in writing if you have the right do you have
our decision reviewed by another person. If you would like a copy of your health information,
contact the Medical Record Department for more information on these services, required
response times, and any additional fees.

Right to have medical information amended. You have the right to request an amendment (which
means correct or supplement) to the medical information about you that we maintain in certain
groups of records. If you believe that we have information that is either inaccurate or incomplete,
we may amend the information to indicate the problem and notify others who have copies of the
inaccurate or incomplete information. If you would like us to amend the information, you must
provide us with a request in writing and explain why you would like us to amend the information.
you may either write us a letter requesting an amendment or fill out an Amendment Request
Form. We or your physician may deny your request in certain circumstances. If we deny your
request, we will explain our reason for doing so in writing. You will have the opportunity to send
us a statement explaining why you disagree with our decision to deny your amendment request
and we will share your statement whenever we disclose the information in the future.

Right to an accounting of disclosures we have made. You have the right to receive a listing of
disclosures we have made for the previous six (6) years. if you would like to receive an accounting,
you may send us a letter making your request, fill out a Disclosure Request Form, or contact our
Privacy and Security Officer. the accounting will not include several types of disclosures, including
disclosures for treatment, payment, or healthcare operations. it will also not include disclosures
made prior to April 14, 2003. If you request an accounting more than once in a twelve (12) month
period, we will charge you a fee to cover the costs of preparing the accounting.

Right request restrictions on uses and disclosures. You have the right to request that we limit the
use and disclosure of medical information about you for treatment, payment, and healthcare
operations. We are not required to agree to your request. If we do agree to your request, we must
follow your restrictions (except if the information is necessary for emergency treatment). You may
cancel the restrictions either in writing or verbally at any time. In addition, we may cancel as a
restriction at any time as long as we notify you of the cancellation and continue to apply the
restriction to information collected before the cancellation.

Right to request an alternative method of contact. You have the right to request to be contacted
at a different location or by a different method. For example, you may prefer to have all written
information mailed to your work address rather than to your home address. We will agree to any
reasonable request for alternative methods of contact. your request must include information as
to how your payment will be handled and whether your alternate contact address is the
appropriate contact location for payment information. your request must be specific and in
writing for completion of an Alternative Contact Request Form. if you cannot provide us with
information that is adequate to ensure our ability to obtain payment on your account, we may
deny your request. We may not require an explanation from you about why you wish to use an
alternative address or method of contact.

Logging a privacy concern. if you believe that your privacy rights have been violated or if you are
dissatisfied with our privacy policies or procedures, you may file a complaint either with us or with
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, you may mail it to IRVING PEDIATRICS, Attention:
Privacy and Security Officer, Muhammad Haq.

To file a written complaint with the Federal Government, send your complaint to Region
IV, Office for Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center,
Suite 3B70, 61 Forsyth Street, SW, Atlanta, GA 30303-8909.

COMPLAINTS AND QUESTIONS ABOUT THE USE OR DISCLOSURE OF YOUR INFORMATION:

If you believe your privacy rights have been violated, contact the agency.
You may contact the agency if you:
(1) have questions about this notice,
(2) need more information about your privacy rights,
(3) need a physical address for the agency, or
(4) are requesting a copy of health information from the agency

  • Texas Department of State Health Services (DSHS): Call 1-512-776-7111 or 1-888-963-
    7111 (toll-free) or email hipaa.privacy@dshs.state.tx.us.
  • Quaestor salts of lab tests performed by the DSHS Laboratory, please call (512) 776-7318
    or visit
    http://www.dshs.state.tx.us/lab/patientresults.aspx.
  • If you are receiving care from DSHS state-operated hospital, contact the hospital’s privacy
    officer, or
  • You may also contact DSHS Consumer Services and Rights Protection/Ombudsman Office
    by mail at Mail Code 2019, P.O. Box 149347 Austin, TX 78714-9347; or by telephone at
    (512) 206-5760 or (800) 252-8154 (toll-free).

If you believe the agency has violated your privacy rights, you can also file a complaint with the:
Secretary Office of Civil Rights Region VI U.S. Department of Health and Human Services
1301 Young St., Suite 1169 Dallas, Texas, 75202
Voice Phone (800) 368-1019
FAX (214) 767-0432
TDD (800) 537-7697

For complaints about a violation of your right to confidentiality by an alcohol or drug abuse
treatment program, Contact the United States Attorney’s Office for the judicial district in which the
violation occurred. The agency prohibits retaliation against you for filing a complaint.

Who this notice applies to. This notice describes IRVING PEDIATRICS practices and those of Any health
care professional authorized to enter information into our consult your medical record.

All entities who access your PHI follow the terms of this notice and are acting as an organized health care
arrangement for purposes of HIPAA. In addition, these entities may share health information with each
other for treatment payment or healthcare operations purposes described in this Notice.