Patient Privacy Statement
ACADIAN EAR, NOSE, THROAT AND FACIAL PLASTIC SURGERY
BRADLEY J. CHASTANT, MD,FACS, DAVID FOREMAN, MD,JEFFREYJ. JOSEPH, MD, FACS, RYAN P. CHASTANT MD, JAMES WHITE JR., MD, CHARLES ANZALONE, MD
1000 W. Pinhook Rd., Suite 201 Lafayette, LA 70503
NOTICE OF PRIVACY PRACTICES
As Required by the Privacy Regulations Created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THISPRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time. We realize that these laws are complicated, but we must provide you with the following important information:
- How we may use and disclose your IIHI.
- Your privacy rights in regard to your IIHI.
- Our obligations concerning the use and disclosure of your IIHI.
The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Privacy Officer or Business Manager
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS The following categories describe the different ways in which we may use and disclose your IIHI.
- Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests) and we may use the results to help us reach a diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice- including, but not limited to, our doctors and nurses- may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children or parents.
- Payment. Our practice may use and disclose o u r IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your HI to bill you directly for services and items.
- Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
- Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind you of an appointment.
- Treatment Options. Our practice may use and disclose your IIHI to inform you of potential treatment options or alternatives.
- Release of Information to Family/Friends. Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.
- Disclosures required by law. Our practice will use and disclose your IIHI when we are required to do so by federal, state or local law.
- Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:
- Reporting child abuse or neglect
- Notifying a person regarding potential exposure to a communicable disease
- Notifying individuals if a product or device they may be using has been recalled.
- Health Oversight Activities. Our practice may disclose your IIHI to a heath oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
- Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
- Law Enforcement. We may release IIHI if asked to do so by a law enforcement official: Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement Concerning a death we believe has resulted from criminal conduct Regarding criminal conduct at our offices In response to a warrant, summons, court order, subpoena or similar legal process To identify/locate a suspect, material witness, fugitive or missing person In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)
D. YOUR RIGHTS REGARDING YOUR IIHI
You have the following right regarding the IIHI that we maintain about you:
- Confidential Communications. You have the right to request that our practice communicate with you about your heath and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to this office specifying the requested method of contact. or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
- Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records but not including psychotherapy notes. You must submit your request in writing to this office in order to inspect and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
- Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our office manager. Al complaints must be submitted in writing. You will not be penalized for filing a complaint.
- Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records of your care.
I hereby give consent to Acadian Ear, Nose, Throat, & Facial Plastic Surgery to use and disclose my protected health information for the purposes of treatment, payment and health care operations. I have received a copy of Acadian Ear, Nose, Throat, & Facial Plastic Surgery Notice of Privacy Practices which provides detailed information about how the practice may use and disclose my protected health information and by agreeing to the terms provided therein will consent to my protected health information being shared with a Health Information Exchange. I understand that I have a right to request a restriction of how my protected health information is used and/or disclosed, but that request must be in writing, that the practice is not required to grant my request, but if the practice does grant the request, it will be binding.