Notice of Medical Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can gain access to this
information. Please review it carefully.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires all medical
records and other individually identifiable health information used or disclosed by us in any form, whether electronically,
on paper, or orally, be kept properly confidential. This Act gives you, the patient, significant new rights to understand and
control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health
information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health
information and how we may use and disclose your health information.
We may use and disclose your medical records only for each of the following purposes: treatment, payment, or health
care operations.
We may also create and distribute de-identified health information by removing all references to individually identifiable
information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health related
benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in
writing and we are required to honor and abide by that written request, except to the extent that we have already taken
actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a
written request to the Privacy Officer:
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our
legal duties and privacy practices with respect to protected health information.
This notice is effective as of January 1, 2003 and we are required to abide by the terms of the Notice of Privacy Practices
currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new
notice provision effective for all protected health information that we maintain. We will post and you may request a written
copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint
with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provision
of this notice or the polices and procedures of our office. We will not retaliate against you for filling a complaint.
Please contact us for more information: For more information about HIPAA or to File a complaint:
The Allergy Clinic The U.S. Department of Health & Human Services
Manuela Gerardo, Administrator Office of Civil Rights
4600 Fairmont Parkway, Ste. 107 200 Independence Avenue, S.W.
Pasadena, TX 77504 Washington, D.C. 20201
(281) 991-6750 (202) 619-0257
Toll Free: 1-877-696-6775
This notice describes how medical information about you may be used and disclosed and how you can gain access to this
information. Please review it carefully.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires all medical
records and other individually identifiable health information used or disclosed by us in any form, whether electronically,
on paper, or orally, be kept properly confidential. This Act gives you, the patient, significant new rights to understand and
control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health
information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health
information and how we may use and disclose your health information.
We may use and disclose your medical records only for each of the following purposes: treatment, payment, or health
care operations.
- Treatment means providing, coordinating, or managing health care and related services by one or more health care
providers. An example of this would include a physical examination.
- Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection
activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company
for payment.
- Health care operations include the business aspects of running our practice, such as conducting quality
assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An
example would be an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable
information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health related
benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in
writing and we are required to honor and abide by that written request, except to the extent that we have already taken
actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a
written request to the Privacy Officer:
- The right to request restrictions on certain uses and disclosures of protected health information, including those
related to disclosures to family members, other relatives, personal friends, or any other person identified by you.
We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by
it unless you agree in writing to remove it.
- The right to reasonable requests to receive confidential communications of protected health information from us by
alternative means or at alternative locations.
- The right to inspect and copy your protected health information.
- The right to amend your protected health information.
- The right to receive an accounting of disclosures of protected health information.
- The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our
legal duties and privacy practices with respect to protected health information.
This notice is effective as of January 1, 2003 and we are required to abide by the terms of the Notice of Privacy Practices
currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new
notice provision effective for all protected health information that we maintain. We will post and you may request a written
copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint
with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provision
of this notice or the polices and procedures of our office. We will not retaliate against you for filling a complaint.
Please contact us for more information: For more information about HIPAA or to File a complaint:
The Allergy Clinic The U.S. Department of Health & Human Services
Manuela Gerardo, Administrator Office of Civil Rights
4600 Fairmont Parkway, Ste. 107 200 Independence Avenue, S.W.
Pasadena, TX 77504 Washington, D.C. 20201
(281) 991-6750 (202) 619-0257
Toll Free: 1-877-696-6775
| The Allergy Clinic Specialists in Allergy & Asthma Care |
| Print and complete all forms included in link. Fax to appropriate office using fax cover sheet included in set of forms. |
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