LUBBOCK DIGESTIVE DISEASE ASSOCIATES
AND SOUTH PLAINS ENDOSCOPY CENTER
NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003
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.
If you should have any questions about this notice, please contact
Pat Wheeler, Privacy Officer, at (806) 793-3141, Extension 210.
WHO WILL FOLLOW THIS NOTICE?
All the doctors and staff of Lubbock Digestive Disease Associates and South Plains Endoscopy Center (LDDA/SPEC) will protect the privacy of your medical information.
Your doctor understands that medical information about you and your health is personal, and is committed to protecting this information. Your doctor will start and keep a record of the care you receive. Your doctor needs this record to:
Communicate with other health care professionals involved in your care
Show that the bills you or your insurance company get are for the care you received
Help educate health care professionals
Provide information for public health officials
Provide you with quality care
Comply with certain legal requirementsThis notice applies to all records of your care at LDDA/SPEC. It tells you about the ways we may use and disclose medical information about you, and also tells you your rights and our obligations regarding the use and disclosure of medical information.
By law, we are required to:
Give you this notice of our legal duties and our privacy practices about your medical information
Follow our Notice of Privacy PracticesHOW WILL WE USE AND DISCLOSE YOUR MEDICAL INFORMATION?
There are different ways we will use and disclose medical information about you. Here is a list of the ways and some examples of each of them. It is impossible to give every example, but all the ways we use and disclose information fall into one of the following:
need to know if you have any heart problems before you have a procedure, Medical information may be disclosed to people outside of LDDA/SPEC who may be involved in your care, such as other doctor’s offices, hospitals, and home health agencies.
For Payment- We will use and disclose medical information about you so that we can bill you or your insurance company so that we get paid for the treatment you have received. We may also tell your insurance company about a treatment you are going to receive to make sure it will be paid for.
For Health Care Operations- We will use medical information about you for our office operations. This helps us run our office efficiently, which helps you receive quality care. For example, your medical information may be used to check that you received appropriate care and that you care was correctly billed.
Appointment Reminders- We will use your information to contact you directly to remind you of an appointment. For example, we will call you or send you a notice that your next appointment with us is coming up.
As Required by Law- We will disclose medical information about you when required by federal or Texas law or regulations.
To Prevent a Serious Threat to Health or Safety- We will use and disclose medical information about you only when necessary to prevent a serious threat to your health and safety or the health and safety of others.
Organ and Tissue Donation- If you are to be an organ or tissue donor, we will release medical information about you to the donation bank as necessary.
Military and Veterans- We will release medical information about you as required by the military authorities.
Workers’ Compensation- We will release medical information about you for worker’s compensation or similar programs that provide benefits for work-related injuries or illnesses.
Qualified Personnel- We will disclose medical information for audits, research, or evaluation to qualified personnel, but the information will not identify you in any way.
Public Health - We will disclose medical information about you for public health risks, including:
o To prevent or control disease, injury or disability
o To report births and deaths
o To report child abuse or neglect
o To report reactions to medications or problems with products
o To notify you if a medication or product you are using is recalled
o To notify a person who may have been exposed to a disease or may be at risk for getting or spreading a disease or condition
o To notify a government authority if we believe you have been a victim of abuse, neglect or domestic violence as required by law
Health Oversight Activities- We will disclose medical information to health oversight agencies authorized by law to oversee the health care system.
Lawsuits and Disputes- If you are involved in certain lawsuits or administrative disputes, we will disclose medical information about you as required by law.
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Law Enforcement- We will release medical information to law enforcement official as required by law.
Coroners, Medical Examiners, and Funeral Directors- We will release medical information to a coroner, medical examiner, or funeral director when necessary to carry out their duties. For example, that information may help to identify a person or determine the cause of death.
Inmates- If you are an inmate of a correctional facility or under the custody of a law enforcement official, we will release medical information about you necessary to protect health and safety of you and all others.
For any reason other than those listed above, we will obtain your authorization before releasing any information.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding medical information we collect and maintain about you:
Right to Inspect and Copy- You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing information. To inspect and copy this medical information, you must write your request and mail or give to Marilou Oliver, Privacy Officer. You will be given access to your medical information within 15 days. If you request a copy of the information there will be a fee charged for the costs of copying and mailing. This fee will not exceed the rate set by the state of Texas. In certain situations, your doctor may deny your request to inspect and copy your records. In that case, another doctor will be asked to review you request and denial, and we will follow the decision of the 2nd doctor.
Right to Amend- If you think that the medical information we have about you is incorrect or incomplete, you have the right to ask us to amend, or change, the information. To request an amendment, you must write your request and the reason for making it, then mail or give to Marilou Oliver, Privacy Officer. We will respond to your request in writing within 15 days. We will deny your request to amend information that:
o
o
Did not come from LDDA/SPECo
Is not part of the medical information in our recordso
Is not part of the information you are permitted to inspect or copyRight to an Accounting of Disclosures- You have the right to request a list of disclosures of your medical information used for purposes other than for treatment, payment, or health care operations. To receive this list, you must write your request and mail or give it to Marilou Oliver, Privacy Officer. Your request must state a timeframe no longer than 6 years, but cannot include
dates before February 26, 2003. We will respond to your request within 15 days. The first list you request within a 12-month period will be free of charge. After the first list, there will be a charge for the cost involved. You will be notified of the cost, and you may choose to withdraw or modify your request.Right to Request Restrictions- You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we
disclose about you to someone involved in your care or for the payment of your care. Your
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doctor and LDDA/SPEC are not required to agree to your request. However, if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions you must write your request and mail or give to Marilou Oliver, Privacy Officer. This must include the following: what information you want to limit; whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply- for example, your husband or wife.
Right to Request Confidential Communications-
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work. To request confidential communications, or to change an already existing request, you must make your request in writing to Marilou Oliver, Privacy Officer, including how and where you wish to be contacted. All reasonable requests will be accepted.CHANGES TO THIS NOTICE
LDDA / SPEC reserves the right to change our privacy practices and to make new provisions for all protected health information we maintain. If we do make changes, a revised Notice of Privacy Practices will be posted in our building. You will receive your own copy upon request.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with us by contacting Marilou Oliver, Privacy Officer. You may also file a written complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. The address is:
Region VI, Office for Civil Rights
U.S. Department of Health and Human Services
1301 Young St., Suite 1169
Dallas, Texas 75202
You will not be penalized in any way for filing a complaint.
We thank you for taking the time to read through this notice. Please turn to the next page and sign the acknowledgement form that you have received a copy of our Notice of Privacy Practices. Then turn to the back of the acknowledgement form and complete the consent form that helps us in disclosing your PHI for the purposes of treatment, payment, and healthcare operations. Return the acknowledgement form and consent form to the receptionist. Please take the notice home with you so that you can refer to it.
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