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 us
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.kentuckianaent.com , calling the office
(502-893-8441) 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
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 Sparkman, 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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