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Summary Of Notice Of
Privacy Practices
Arlington Center for Dermatology
711 East Lamar Blvd. Suite 200, Arlington, Texas 76011
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The following is a brief summary of your rights and our
responsibilities as detailed in the attached Notice of Privacy
Practices (the “Notice”). This Summary is for your convenience
and is not a substitute for reading the entire Notice and does
not modify the terms of the Notice.
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| 1. |
Uses and Disclosures of Your Health Information.
We may use the information we develop and collect for
treatment by our practice or disclose the information to
others to whom we refer you for treatment, for payment
for these services and for certain health care
“operations” such as improving the competence and
quality of our staff and business planning and
management. We may disclose your information to our
business associates such as medical transcriptionists,
billing services and others who assist in the operations
of our practice. We may call you to remind you of
appointments and may leave a message on your answering
machine if you have one. We may also disclose
information to your family about your location, general
condition or death. If you are available and able, we
will ask your consent first. We may also use your
information to recommend products or services related to
your care but will not use or disclose your medical
information for marketing purposes without your written
authorization. Your medical information may be disclosed
without your authorization as required by law, for
public health purposes, healthcare oversight, including
audits and investigations, judicial and administrative
proceedings, subject to the limits imposed by state and
federal law, and certain other purposes. We may disclose
your health information to researchers conducting
research with respect to which your written
authorization is not required as approved by in
Institutional Review Board or privacy board, in
compliance with governing law.
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| 2. |
Other Uses and Disclosures. Except as
described in the Notice, we will not use or disclose
your medical information without your written
authorization. You can revoke an authorization at any
time, except to the extent that we have already taken
action in reliance on the authorization.
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| 3. |
Your Health Information Rights. You have a
number of rights under state and/or federal law which
are subject to the terms and conditions specified in the
Notice:
 a)
You may request restrictions on certain uses and
disclosures of your information
b)
You may request that you receive your information from
us in a certain way
c)
You may inspect and copy your medical records
d)
You may request an amendment to any record you believe
is inaccurate
e)
You may request an accounting of disclosures made of
your records
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| 4. |
Changes to the Notice. We reserve the right
to change the Notice. If we do so, we will post it in
our office, and on our website, and provide a copy upon
request.
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| 5. |
Complaints. You may file a complaint to our
Privacy Official whose name is above or with the federal
government as detailed in the Notice. You will not be
penalized for filing any complaint.
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Notice of Privacy Practices
Arlington Center for Dermatology
711 East Lamar Blvd. Suite 200, Arlington, Texas 76011
Practice Manager, Privacy Official
817-795-7546
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Effective Date: April 1, 2008
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.
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We understand the importance of privacy, and are committed to
maintaining the confidentiality of your medical information. We
make a record of the medical care we provide, and may receive
such records from others. We use these records to provide or
enable other health care providers to provide quality medical
care, to obtain payment for services provided to you as allowed
by your health plan and to enable us to meet our professional
and legal obligations to operate this medical practice properly.
We are required by law to maintain the privacy of protected
health information and to provide individuals with notice of our
legal duties and privacy practices with respect to protected
health information. This notice describes how we may use and
disclose your medical information. It also describes your rights
and our legal obligations with respect to your medical
information. If you have any questions about this Notice, please
contact our Privacy Officer listed above.
A.How this
Medical Practice May Use or Disclose Your Health Information
The law permits us to use or disclose your health information
for the following purposes:
1.Treatment.
We may use medical information about you to provide your medical
care. We disclose medical information to our employees and
others who are involved in providing the care you need. For
example, we may share your medical information with other
physicians or other health care providers who will provide
services, which we do not provide. We may also share this
information with a pharmacist who needs it to dispense a
prescription to you, or a laboratory that performs a test.
2.Payment.
We may use and disclose medical information about you to obtain
payment for the services we provide. For example, we may give
your health plan the information it requires before it will pay
us. We may also disclose information to other health care
providers to assist them in obtaining payment for services they
have provided to you.
3.Health
Care Operations. We may use and disclose medical information
about you to operate this medical practice. For example, we may
use and disclose this information to review and improve the
quality of care we provide, or the competence and qualifications
of our professional staff. We may also use and disclose this
information to request that your health plan authorize services
or referrals. We may also use and disclose this information as
necessary for medical reviews, legal services and audits,
including fraud and abuse detection and compliance programs and
business planning and management. We may also share your
information with other health care providers, a health care
clearinghouse or health plans that have a relationship with you
when they request this information, to help them with their
quality assessment and improvement activities, their efforts to
improve health or reduce health care costs, their review of
compliance, qualifications and performance of health care
professionals, their training programs, their accreditation,
certification or licensing activities, or their health care
fraud and abuse detection and compliance efforts.
4.Business
Associates. We may share your medical information with our
"business associates", such as our billing service that performs
administrative services for us. We have a written contract with
each of these business associates that contains terms requiring
them to protect the confidentiality of your medical information.
5.Appointment
Reminders. We may use and disclose medical information to
contact and remind you about appointments. If you are not home,
we may leave this information with the person answering the
phone or on your answering machine.
6.Sign in
sheet. We may ask you to sign in when you arrive at our
office. We may also call out your name when we are ready to see
you.
7.Notification
and communication with family. We may disclose your health
information to a family member or a close friend or other person
you identify where relevant to that person’s involvement in your
care or payment for your care. We may disclose your health
information to notify or assist in notifying a family member,
your personal representative or another person responsible for
your care about your location, your general condition or in the
event of your death. In the event of a disaster, we may disclose
information to a relief organization so that they may coordinate
these notification efforts. If you are able and available to
agree or object, we will give you the opportunity to object
prior to making these disclosures, although we may disclose this
information in a disaster even over your objection if we believe
it is necessary to respond to the emergency circumstances. If
you are unable or unavailable to agree or object, our health
professionals will use their best judgment in communicating with
your family and others.
8.Marketing.
We may contact you to give you information about product or
services related to your treatment, case management or care
coordination, or to direct or recommend other treatments or
health-related benefits and services that may be of interest to
you or to provide you with small gifts. We may also encourage
you to purchase a product or service when we see you. We will
not use of disclose your medical information for marketing
purposes without your written authorization.
9.Required
by law. As required by law, we will use and disclose your
health information, but we will limit our use or disclosure to
the relevant requirements of the law. When the law requires us
to report abuse, neglect or domestic violence, or respond to
judicial or administrative proceedings, or to law enforcement
officials, we will further comply with the requirement set forth
below concerning those activities.
10.Public
health. We may, and are sometimes required by law to
disclose your health information to public health authorities
for purposes related to: preventing or controlling disease,
injury or disability; reporting child, elder or dependent adult
abuse or neglect; reporting domestic violence; reporting to the
Food and Drug Administration problems with products and
reactions to medications; and reporting disease or infection
exposure. When we report suspected elder or dependent adult
abuse or domestic violence, we will inform you or your personal
representative promptly unless in our best professional
judgment, we believe the notification would place you at risk of
serious harm or would require informing a personal
representative we believe is responsible for the abuse or harm.
11.Health
oversight activities. We may, and are sometimes required by
law to disclose your health information to health oversight
agencies during the course of audits, investigations,
inspections, licensure and other proceedings.
12.Judicial
and administrative proceedings. We may, and are sometimes
required by law, to disclose your health information in the
course of any administrative or judicial proceeding to the
extent expressly authorized by a court or administrative order.
We may also disclose information about you in response to a
subpoena, discovery request or other lawful process if
reasonable efforts have been made to notify you of the request
and you have not objected, or if your objections have been
resolved by a court or administrative order.
13.Law
enforcement. We may, and are sometimes required by law, to
disclose your health information to a law enforcement official
for purposes such as identifying of locating a suspect,
fugitive, material witness or missing person, complying with a
court order, warrant, grand jury subpoena and other law
enforcement purposes.
14.Coroners.
We may, and are often required by law, to disclose your health
information to coroners in connection with their investigations
of deaths.
15.Organ
or tissue donation. We may disclose your health information
to organizations involved in procuring, banking or transplanting
organs and tissues.
16.To
avert a serious threat to health or safety. We may, and are
sometimes required by law, to disclose your health information
to appropriate persons in order to prevent or lessen a serious
and imminent threat to the health or safety of a particular
person or the general public.
17.Specialized
government functions. We may disclose your health
information for military or national security purposes or to
correctional institutions or law enforcement officers that have
you in their lawful custody.
18.Worker’s
compensation. We may disclose your health information as
necessary to comply with worker’s compensation laws. For
example, to the extent your care is covered by workers'
compensation, we will make periodic reports to your employer
about your condition. We are also required by law to report
cases of occupational injury or occupational illness to the
employer or workers' compensation insurer.
19.Change
of Ownership. In the event that this medical practice is
sold or merged with another organization, your health
information/record may be transferred the new owner, although
you will maintain the right to request that copies of your
health information be transferred to another physician or
medical group.
20.Research.
We may disclose your health information to researchers
conducting research with respect to which your written
authorization is not required as approved by an Institutional
Review Board or privacy board, in compliance with governing law.
B.When
This Medical Practice May Not Use or Disclose Your Health
Information
Except as described in this Notice of Privacy Practices, this
medical practice will not use or disclose health information,
which identifies you without your written authorization. If you
do authorize this medical practice to use or disclose your
health information for another purpose, you may revoke your
authorization in writing at any time, except to the extent that
we have already taken action in reliance on the authorization.
C.Your
Health Information Rights
1.Right to
Request Special Privacy Protections. You have the right to
request restrictions on certain uses and disclosures of your
health information, by submitting a written request specifying
what information you want to limit and what limitations on our
use or disclosure of that information you wish to have imposed.
We reserve the right to accept or reject your request, and will
notify you of our decision.
2.Right to
Request Confidential Communications. You have the right to
request that you receive your health information in a specific
way or at a specific location. For example, you may ask that we
send information to a particular e-mail account or to your work
address. We will comply with all reasonable requests submitted
in writing which specify how or where you wish to receive these
communications.
3.Right to
Inspect and Copy. You have the right to inspect and copy
your health information, with limited exceptions. To access your
medical information, you must submit a written request detailing
what information you want access to and whether you want to
inspect it or get a copy of it. We will charge a reasonable fee,
as allowed by Connecticut law. We may deny your request under
limited circumstances.
4.Right to
Amend or Supplement. You have a right to request that we
amend your health information that you believe is incorrect or
incomplete. You must make a request to amend in writing, and
include the reasons you believe the information is inaccurate or
incomplete. We are not required to change your health
information, and will provide you with information about this
medical practice's denial and how you can disagree with the
denial. We may deny your request if we do not have the
information, if we did not create the information (unless the
person or entity that created the information is no longer
available to make the amendment), if you would not be permitted
to inspect or copy the information at issue, or if the
information is accurate and complete as is.
5.Right to
an Accounting of Disclosures. You have a right to receive an
accounting of disclosures of your health information made by
this medical practice, except that this medical practice does
not have to account for the disclosures provided to you or
pursuant to your written authorization, or as described in
paragraphs 1 (treatment), 2 (payment), 3 (health care
operations), 7 (notification and communication with family) and
17 (certain government functions) of Section A of this Notice of
Privacy Practices or disclosures of data which exclude direct
patient identifiers for purposes of research or public health or
disclosures which are incident to a use or disclosure otherwise
permitted or authorized by law, or the disclosures to a health
oversight agency or law enforcement official to the extent this
medical practice has received notice from that agency or
official that providing this accounting would be reasonably
likely to impede their activities and certain other disclosures.
6.Right to
Receive a Notice of Privacy Practices. You have a right to
receive a paper copy of this Notice of Privacy Practices, even
if you have previously requested its receipt by e-mail.
If you would like to have a more detailed explanation of these
rights or if you would like to exercise one or more of these
rights, contact our Privacy Officer listed at the top of this
Notice of Privacy Practices.
D.Special
Rules Regarding Disclosure of Psychiatric, Substance Abuse and
HIV-Related Information
Under Connecticut or federal law, additional restrictions may
apply to disclosures of health information that relates to care
for psychiatric conditions, substance abuse or HIV-related
testing and treatment. This information may not be disclosed
without your specific written permission, except as may be
specifically required or permitted by Connecticut or federal
law. The following are examples of disclosures that may be made
without your specific written permission:
* Psychiatric information. We may disclose psychiatric
information to a mental health program if needed for your
diagnosis or treatment. We may also disclose very limited
psychiatric information for payment purposes.
* HIV-related information. We may disclose HIV-related
information for purposes of treatment or payment.
* Substance abuse treatment. We may disclose information
obtained from a substance abuse program in an emergency.
E.Changes
to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices
at any time in the future. Until such amendment is made, we are
required by law to comply with this Notice. After an amendment
is made, the revised Notice of Privacy Protections will apply to
all protected health information that we maintain, regardless of
when it was created or received. We will keep a copy of the
current notice posted in our reception area, and provide you
with a copy upon request. We will also post the current notice
on our website.
F.Complaints
Complaints about this Notice of Privacy Practices or how this
medical practice handles your health information should be
directed to our Privacy Officer listed at the top of this Notice
of Privacy Practices.
You may also submit a complaint to:
Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
You will not be penalized for filing a complaint.
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