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Notice
of Privacy Practices
Kentuckiana
Ear, Nose & Throat, PSC
6420 Dutchmans Parkway, #380 Louisville,
KY 40205
225 Abraham Flexner Way, # 401
Louisville, KY 40202
1405 Spring Street
Jeffersonville, IN 47130
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 have any questions about this
Notice please contact: our Privacy Contact who is
Linda Sparkman, Privacy Officer, 812-283-0728
This
Notice of Privacy Practices describes how we may use and disclose
your protected health information to carry out treatment, payment
or health care operations and for other purposes that are
permitted or required by law. It also describes your rights to
access and control your protected health information. “Protected
health information” is information about you, including
demographic information, that may identify you and that relates to
your past, present or future physical or mental health or
condition and related health care services.
We
are required to abide by the terms of this Notice of Privacy
Practices. We may change the terms of our notice, at any time. The
new notice will be effective for all protected health information
that we maintain at that time. Upon your request, we will provide
you with any revised Notice of Privacy Practices by www.yourentmd.com
, calling the office (502-583-9425) and requesting that a
revised copy be sent to you in the mail or asking for one at the
time of your next appointment.
1. Uses and Disclosures of Protected Health Information
Uses
and Disclosures of Protected Health Information Based Upon Your
Written Consent
You
will be asked by your physician to sign a consent form. Once you
have consented to use and disclosure of your protected health
information for treatment, payment and health care operations by
signing the consent form, your physician will use or disclose your
protected health information as described in this Section 1. Your
protected health information may be used and disclosed by your
physician, our office staff and others outside of our office that
are involved in your care and treatment for the purpose of
providing health care services to you. Your protected health
information may also be used and disclosed to pay your health care
bills and to support the operation of the physician’s practice.
Following
are examples of the types of uses and disclosures of your
protected health care information that the physician’s office is
permitted to make once you have signed our consent form. These
examples are not meant to be exhaustive, but to describe the types
of uses and disclosures that may be made by our office once you
have provided consent.
Treatment: We will use and disclose your protected health
information to provide, coordinate, or manage your health care and
any related services. This includes the coordination or management
of your health care with a third party that has already obtained
your permission to have access to your protected health
information. For example, we would disclose your protected health
information, as necessary, to a home health agency that provides
care to you. We will also disclose protected health information to
other physicians who may be treating you when we have the
necessary permission from you to disclose your protected health
information. For example, your protected health information may be
provided to a physician to whom you have been referred to ensure
that the physician has the necessary information to diagnose or
treat you.
In
addition, we may disclose your protected health information from
time-to-time to another physician or health care provider (e.g., a
specialist or laboratory) who, at the request of your physician,
becomes involved in your care by providing assistance with your
health care diagnosis or treatment to your physician.
Payment: Your protected health information will be used, as
needed, to obtain payment for your health care services. This may
include certain activities that your health insurance plan may
undertake before it approves or pays for the health care services
we recommend for you such as; making a determination of
eligibility or coverage for insurance benefits, reviewing services
provided to you for medical necessity, and undertaking utilization
review activities. For example, obtaining approval for a hospital
stay may require that your relevant protected health information
be disclosed to the health plan to obtain approval for the
hospital admission.
Healthcare Operations: We may use or disclose, as-needed,
your protected health information in order to support the business
activities of your physician’s practice. These activities
include, but are not limited to, quality assessment activities,
employee review
activities,
training of medical students, licensing, marketing and fundraising
activities, and conducting or arranging for other business
activities.
For
example, we may disclose your protected health information to
medical school students who see patients at our office. In
addition, we may use a sign-in sheet at the registration desk
where you will be asked to sign your name and indicate your
physician. We may also call you by name in the waiting room when
your physician is ready to see you. We may use or disclose your
protected health information, as necessary, to contact you to
remind you of your appointment.
We
will share your protected health information with third party
“business associates” that perform various activities (e.g.,
billing, transcription services) for the practice. Whenever an
arrangement between our office and a business associate involves
the use or disclosure of your protected health information, we
will have a written contract that contains terms that will protect
the privacy of your protected health information.
We
may use or disclose your protected health information, as
necessary, to provide you with information about treatment
alternatives or other health-related benefits and services that
may be of interest to you. We may also use and disclose your
protected health information for other marketing activities. For
example, your name and address may be used to send you a
newsletter about our practice and the services we offer. We may
also send you information about products or services that we
believe may be beneficial to you. You may contact our Privacy
Contact to request that these materials not be sent to you.
We
may use or disclose your demographic information and the dates
that you received treatment from your physician, as necessary, in
order to contact you for fundraising activities supported by our
office. If you do not want to receive these materials, please
contact our Privacy Contact and request that these fundraising
materials not be sent to you.
Uses
and Disclosures of Protected Health Information Based upon Your
Written Authorization
Other
uses and disclosures of your protected health information will be
made only with your written authorization, unless otherwise
permitted or required by law as described below. You may revoke
this authorization, at any time, in writing, except to the extent
that your physician or the physician’s practice has taken an
action in reliance on the use or disclosure indicated in the
authorization.
Other
Permitted and Required Uses and Disclosures That May Be Made With
Your Consent, Authorization or Opportunity to Object
We
may use and disclose your protected health information in the
following instances. You have the opportunity to agree or object
to the use or disclosure of all or part of your protected health
information. If you are not present or able to agree or object to
the use or disclosure of the protected health information, then
your physician may, using professional judgment, determine whether
the disclosure is in your best interest. In this case, only the
protected health information that is relevant to your health care
will be disclosed.
Others Involved in Your Healthcare:
Unless you object, we may disclose to a member of your family, a
relative, a close friend or any other person you identify, your
protected health information that directly relates to that
person’s involvement in your health care. If you are unable to
agree or object to such a disclosure, we may disclose such
information as necessary if we determine that it is in your best
interest based on our professional judgment. We may use or
disclose protected health information to notify or assist in
notifying a family member, personal representative or any other
person that is responsible for your care of your location, general
condition or death. Finally, we may use or disclose your protected
health information to an authorized public or private entity to
assist in disaster relief efforts and to coordinate uses and
disclosures to family or other individuals involved in your health
care.
Emergencies: We may use or disclose your protected health
information in an emergency treatment situation. If this happens,
your physician shall try to obtain your consent as soon as
reasonably practicable after the delivery of treatment. If your
physician or another physician in the practice is required by law
to treat you and the physician has attempted to obtain your
consent but is unable to obtain your consent, he or she may still
use or disclose your protected health information to treat you.
Communication Barriers: We may use and disclose your
protected health information if your physician or another
physician in the practice attempts to obtain consent from you but
is unable to do so due to substantial communication barriers and
the physician determines, using professional judgment, that you
intend to consent to use or disclosure under the circumstances.
Other
Permitted and Required Uses and Disclosures That May Be Made
Without Your Consent, Authorization or Opportunity to Object
We
may use or disclose your protected health information in the
following situations without your consent or authorization. These
situations include:
Required By Law: We may use or disclose your protected health
information to the extent that the use or disclosure is required
by law. The use or disclosure will be made in compliance with the
law and will be limited to the relevant requirements of the law.
You will be notified, if required by law, of any such uses or
disclosures.
Public Health: We may disclose your protected health information for
public health activities and purposes to a public health authority
that is permitted by law to collect or receive the information.
The disclosure will be made in accordance with state law for the
purpose of controlling disease, injury or disability. We may also
disclose your protected health information, if directed by the
public health authority, to a foreign government agency that is
collaborating with the public health authority.
Communicable Diseases: We may disclose your protected
health information, according to state law, to a person who may
have been exposed to a communicable disease or may otherwise be at
risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health
information to a health oversight agency for activities authorized
by law, such as audits, investigations, and inspections. Oversight
agencies seeking this information include government agencies that
oversee the health care system, government benefit programs, other
government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected
health information to a public health authority that is authorized
by law to receive reports of child abuse or neglect. In addition,
we may disclose your protected health information if we believe
that you have been a victim of abuse, neglect or domestic violence
to the governmental entity or agency authorized to receive such
information under law. In this case, the disclosure will be made
consistent with the requirements of applicable federal and state
laws.
Food and Drug Administration: We may disclose your protected
health information to a person or company required by the Food and
Drug Administration to report adverse events, product defects or
problems, biologic product deviations, track products; to enable
product recalls; to make repairs or replacements, or to conduct
post marketing surveillance, as required.
Legal Proceedings: We may disclose protected health
information in the course of any judicial or administrative
proceeding, in response to an order of a court or administrative
tribunal (to the extent such disclosure is expressly authorized),
in certain conditions in response to a subpoena, discovery request
or other lawful process.
Law Enforcement: We may also disclose protected health information, so
long as applicable legal requirements are met, for law enforcement
purposes. These law enforcement purposes include (1) legal
processes and otherwise required by law, (2) limited information
requests for identification and location purposes, (3) pertaining
to victims of a crime, (4) suspicion that death has occurred as a
result of criminal conduct, (5) in the event that a crime occurs
on the premises of the practice, and (6) medical emergency (not on
the Practice’s premises) and it is likely that a crime has
occurred.
Coroners, Funeral Directors, and Organ Donation:
We may disclose protected health information to a coroner or
medical examiner for identification purposes, determining cause of
death or for the coroner or medical examiner to perform other
duties authorized by law. We may also disclose protected health
information to a funeral director, as authorized by law, in order
to permit the funeral director to carry out their duties. We may
disclose such information in reasonable anticipation of death.
Protected health information may be used and disclosed for
cadaveric organ, eye or tissue donation purposes.
Research: We may disclose your protected health information to
researchers when their research has been approved by an
institutional review board that has reviewed the research proposal
and established protocols to ensure the privacy of your protected
health information.
Criminal Activity: Consistent with applicable federal
and state laws, we may disclose your protected health information,
if we believe that the use or disclosure is necessary to prevent
or lessen a serious and imminent threat to the health or safety of
a person or the public. We may also disclose protected health
information if it is necessary for law enforcement authorities to
identify or apprehend an individual.
Military Activity and National Security:
When the appropriate conditions apply, we may use or disclose
protected health information of individuals who are Armed Forces
personnel (1) for activities deemed necessary by appropriate
military command authorities; (2) for the purpose of a
determination by the Department of Veterans Affairs of your
eligibility for benefits, or (3) to foreign military authority if
you are a member of that foreign military services. We may also
disclose your protected health information to authorized federal
officials for conducting national security and intelligence
activities, including for the provision of protective services to
the President or others legally authorized.
Workers’ Compensation: Your protected health information
may be disclosed by us as authorized to comply with workers’
compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health
information if you are an inmate of a correctional facility and
your physician created or received your protected health
information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make
disclosures to you and when required by the Secretary of the
Department of Health and Human Services to investigate or
determine our compliance with the requirements of Section 164.500
et. seq.
2. Your Rights
Following
is a statement of your rights with respect to your protected
health information and a brief description of how you may exercise
these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of
protected health information about you that is contained in a
designated record set for as long as we maintain the protected
health information. A “designated record set” contains medical
and billing records and any other records that your physician and
the practice uses for making decisions about you.
Under
federal law, however, you may not inspect or copy the following
records; psychotherapy notes; information compiled in reasonable
anticipation of, or use in, a civil, criminal, or administrative
action or proceeding, and protected health information that is
subject to law that prohibits access to protected health
information. Depending on the circumstances, a decision to deny
access may be reviewable. In some circumstances, you may have a
right to have this decision reviewed. Please contact our Privacy
Contact if you have questions about access to your medical record.
You have the right to request a restriction of your protected health
information. This means you may ask us not to use or disclose any
part of your protected health information for the purposes of
treatment, payment or healthcare operations. You may also request
that any part of your protected health information not be
disclosed to family members or friends who may be involved in your
care or for notification purposes as described in this Notice of
Privacy Practices. Your request must state the specific
restriction requested and to whom you want the restriction to
apply.
Your
physician is not required to agree to a restriction that you may
request. If physician believes it is in your best interest to
permit use and disclosure of your protected health information,
your protected health information will not be restricted. If your
physician does agree to the requested restriction, we may not use
or disclose your protected health information in violation of that
restriction unless it is needed to provide emergency treatment.
With this in mind, please discuss any restriction you wish to
request with your physician. You may request a restriction by
completing, including signature, and returning a Kentuckiana Ear
Nose & Throat, PSC Request for Restriction of Disclosure form.
However, the applicable federal and state laws provide
certain exceptions your ability to restrict access to your
personal health information.
You have the right to request to receive confidential communications from
us by alternative means or at an alternative location.
We will accommodate reasonable requests. We may also condition
this accommodation by asking you for information as to how payment
will be handled or specification of an alternative address or
other method of contact. We will not request an explanation from
you as to the basis for the request. Please make this request in
writing to our Privacy Contact.
You may have the right to have your physician amend your protected health
information. This means you may request an amendment of protected
health information about you in a designated record set for as
long as we maintain this information. In certain cases, we may
deny your request for an amendment. If we deny your request for
amendment, you have the right to file a statement of disagreement
with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal. Please contact our
Privacy Contact to determine if you have questions about amending
your medical record.
You have the right to receive an accounting of certain disclosures we
have made, if any, of your protected health information.
This right applies to disclosures for purposes other than
treatment, payment or healthcare operations as described in this
Notice of Privacy Practices. It excludes disclosures we may have
made to you, for a facility directory, to family members or
friends involved in your care, or for notification purposes. You
have the right to receive specific information regarding these
disclosures that occurred after April 14, 2003. You may request a
shorter timeframe. The right to receive this information is
subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us,
upon request, even if you have agreed to accept this notice
electronically.
3. Complaints
You
may complain to us or to the Secretary of Health and Human
Services if you believe your privacy rights have been violated by
us. You may file a complaint with us by notifying our privacy
contact of your complaint. We will not retaliate against you for
filing a complaint.
You
may contact our Privacy Contact, Linda SAparkman, Privacy Officer,
at 812-283-0728 or at Kentuckianaent4@aol.com
for further information about the complaint process.
This
notice was published and becomes effective: February 4, 2003
Acknowledgement of Receipt
I
acknowledge I have been given a copy of and read the Kentuckiana
Ear Nose & Throat, PSC Notice of Privacy Practices.
____________________________________
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Signature
Date
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