NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
THIS NOTICE DESCRIBES HOW HEALTH 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 Officer by dialing the
office number listed above.
Understanding Your Health Record
Each time you visit our office, a record of your visit is made. This record may contain your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by this office.
Our Responsibilities
This office is required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice.
Uses and Disclosures
How we may use and disclose Health Information about you.
The following categories describe examples of the way we use and disclose health information:
For Treatment: We may use health information about you to provide treatment or services. We may disclose health information about you to doctors, nurses, technicians, or hospital personnel who are involved in your care. We may also provide a subsequent healthcare provider with copies of various records that would assist him or her in treating you in the future.
For Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.
For Health Care Operations: Our office may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all the patients we serve. We may remove information that identifies you from this set of health information to protect your privacy.
We may also use and disclose health information:
Business Associates: There are some services provided in our office through contracts with business associates. An example may be the use of an outside laboratory. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have asked them to do. They may bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Individuals Involved in Your Care or Payment for Your Care: We may release health information about you to a friend or family member who is involved in your medical care or who helps pay for your care.
Research: We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research and granted a waiver of the authorization requirement.
Organized Health Care Arrangement: Information will be shared as necessary to carry out treatment, payment and health care operations. Other physicians and caregivers may have receive access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time of your visit in their office.
As required by law, we may also use and disclose health information for the following types of entities, including but not limited to:
State-Specific Requirements: Texas has some reporting requirements including population-based activities relating to improving health or reducing health care costs. Some Texas privacy laws may apply additional legal requirements. If the state privacy laws are more stringent than federal privacy laws, the state law preempts the federal law.
Your Health Information Rights
Although your health record itself is the physical property of William H. Bordelon, MD, P.A., the protected health information in the record belongs to you. You have the right to:
Inspect and Copy: You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care. Usually, this includes medical and billing records. We may be allowed to charge you for the cost of making the copy.- We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by this office. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.
An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of certain disclosures we make of your health information for purposes other than treatment, payment or health care operations where an authorization was not required.
Request Restrictions: You have the right to request a restriction or limitation on the health 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 health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
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 may ask that we contact you at work instead of your home. This office will grant reasonable requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by this office and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To exercise any of your right, please obtain the required forms from the Privacy Officer and submit your request in writing.
Changes to this Notice: We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in this office and include the effective date. In addition, each time you register in our office, we will offer you a copy of the current notice in effect.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with this office by contacting our Privacy Officer All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Other Uses of Health Information: Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
William H. Bordelon, MD, P.A.
Privacy Officer: Holly Gwynn
Telephone Number 806.359.5874
William H. Bordelon, MD, PA Urology | 1600 S. Coulter Building A Suite 100 Amarillo, TX 79106 | Tel: 806.359.5874 | Fax: 806.359.9384