Notice of Privacy Practices for Protected Health Information
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!
With your consent, the practice is permitted by federal privacy laws to make uses and
disclosures of your health information for purposes of treatment, payment, and health
care operations. Protected health information is the information we create and obtain in
providing our services to you. Such information may include documenting your
symptoms, examination and test results, diagnoses, treatment, and applying for future
care or treatment. It also includes billing documents for those services.
Example of uses of your health information for treatment purposes:
A nurse obtains treatment information about you and records it in a health record. During
the course of your treatment, the doctor determines a need to consult with another
specialist in the area. The doctor will share the information with such specialist and
obtain input.
Example of use of your health information for payment purposes:
We submit a request for payment to your health insurance company. The health
insurance company requests information from us regarding medical care given. We will
provide information to them about you and the care given.
Example of Use of Your Information for Health Care Operations:
We obtain services from our insurers or other business associates such as quality
assessment, quality improvement, outcome evaluation, protocol and clinical guidelines
development, training programs, credentialing, medical review, legal services, and
insurance. We will share information about you with such insurers or other business
associates as necessary to obtain these services.
Your Health Information Rights
The health record we maintain and billing records are the physical property of the
practice. The information in it, however, belongs to you. You have a right to:
• Request a restriction on certain uses and disclosures of your health information by
delivering the request in writing to our office. We are not required to grant the request
but we will comply with any request granted;
• Request that you be allowed to inspect and copy your health record and billing
record—you may exercise this right by delivering the request in writing to our office;
• Appeal a denial of access to your protected health information except in certain
circumstances;
• Request that your health care record be amended to correct incomplete or
incorrect information by delivering a written request to our office;
• File a statement of disagreement if your amendment is denied, and require that the
request for amendment and any denial be attached in all future disclosures of your
protected health information;
• Obtain an accounting of disclosures of your health information as required to be
maintained by law by delivering a written request to our office. An accounting will not
include internal uses of information for treatment, payment, or operations, disclosures
made to you or made at your request, or disclosures made to family members or friends in
the course of providing care;
• Request that communication of your health information be made by alternative
means or at an alternative location by delivering the request in writing to our office; and,
• Revoke authorizations that you made previously to use or disclose information
except to the extent information or action has already been taken by delivering a written
revocation to our office.
If you want to exercise any of the above rights, please contact [insert name of designated
staff member, phone number, or address], in person or in writing, during normal hours. S
[he] will provide you with assistance on the steps to take to exercise your rights.
Our Responsibilities
The practice is required to:
• Maintain the privacy of your health information as required by law;
• Provide you with a notice of our duties and privacy practices as to the information
we collect and maintain about you;
• Abide by the terms of this Notice;
• Notify you if we cannot accommodate a requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate
health information with you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices
and access practices and to enact new provisions regarding the protected health
information we maintain. If our information practices change, we will amend our
Notice. You are entitled to receive a revised copy of the Notice by calling and
requesting a copy of our "Notice" or by visiting our office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem
regarding the handling of your information, you may contact [insert name, title, and
telephone number of internal contact person].
Additionally, if you believe your privacy rights have been violated, you may file a written
complaint at our office by delivering the written complaint to Dr. Wiggins. You may also
file a complaint by mailing it or e-mailing it to the Secretary of Health and Human
Services whose street address and e-mail address is:
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
www.hhs.gov.
• We cannot, and will not, require you to waive the right to file a complaint with the
Secretary of Health and Human Services (HHS) as a condition of receiving treatment
from the practice.
• We cannot, and will not, retaliate against you for filing a complaint with the
Secretary.
Other Disclosures and Uses
Notification
Unless you object, we may use or disclose your protected health information to notify, or
assist in notifying, a family member, personal representative, or other person responsible
for your care, about your location, and about your general condition, or your death.
Communication with Family
Using our best judgment, we may disclose to a family member, other relative, close
personal friend, or any other person you identify, health information relevant to that
person's involvement in your care or in payment for such care if you do not object or in
an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events
with respect to products and product defects, or post-marketing surveillance information
to enable product recalls, repairs, or replacements.
Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your
protected health information to the extent necessary to comply with laws relating to
Workers Compensation.
Public Health
As required by law, we may disclose your protected health information to public health or
legal authorities charged with preventing or controlling disease, injury, or disability.
Abuse & Neglect
We may disclose your protected health information to public authorities as allowed by
law to report abuse or neglect.
Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution, or its
agents, your protected health information necessary for your health and the health and
safety of other individuals.
Law Enforcement
We may disclose your protected health information for law enforcement purposes as
required by law, such as when required by a court order, or in cases involving felony
prosecutions, or to the extent an individual is in the custody of law enforcement.
Health Oversight
Federal law allows us to release your protected health information to appropriate health
oversight agencies or for health oversight activities.
Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or
administrative proceeding as allowed or required by law, with your consent, or as directed
by a proper court order.
Other Uses
Other uses and disclosures besides those identified in this Notice will be made only as
otherwise authorized by law or with your written authorization and you may revoke the
authorization as previously provided.
Website
We maintain a website that provides information about our entity, this Notice will be on
the website.
ADDITIONAL Uses and Disclosures
Research
• We may disclose 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.
Disaster Relief
• We may use and disclose your protected health information to assist in disaster
relief efforts.
Funeral Directors/Coroners
• We may disclose your protected health information to funeral directors or coroners
consistent with applicable law to allow them to carry out their duties.
Organ Procurement Organizations
• Consistent with applicable law, we may disclose your protected health information
to organ procurement organizations or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose of tissue donation and transplant.
Marketing
• We may contact you to provide you with information about treatment alternatives,
or with information about other health-related benefits and services that may be of
interest to you.
Fund Raising
• We may contact you as part of a fund raising effort.
For Specialized Governmental Functions
• We may disclose your protected health information for specialized government
functions as authorized by law, such as to Armed Forces personnel, for national security
purposes, or to public assistance program personnel.
Effective Date: 7-11-2003
and how you can get access to this information. Please review it carefully!
With your consent, the practice is permitted by federal privacy laws to make uses and
disclosures of your health information for purposes of treatment, payment, and health
care operations. Protected health information is the information we create and obtain in
providing our services to you. Such information may include documenting your
symptoms, examination and test results, diagnoses, treatment, and applying for future
care or treatment. It also includes billing documents for those services.
Example of uses of your health information for treatment purposes:
A nurse obtains treatment information about you and records it in a health record. During
the course of your treatment, the doctor determines a need to consult with another
specialist in the area. The doctor will share the information with such specialist and
obtain input.
Example of use of your health information for payment purposes:
We submit a request for payment to your health insurance company. The health
insurance company requests information from us regarding medical care given. We will
provide information to them about you and the care given.
Example of Use of Your Information for Health Care Operations:
We obtain services from our insurers or other business associates such as quality
assessment, quality improvement, outcome evaluation, protocol and clinical guidelines
development, training programs, credentialing, medical review, legal services, and
insurance. We will share information about you with such insurers or other business
associates as necessary to obtain these services.
Your Health Information Rights
The health record we maintain and billing records are the physical property of the
practice. The information in it, however, belongs to you. You have a right to:
• Request a restriction on certain uses and disclosures of your health information by
delivering the request in writing to our office. We are not required to grant the request
but we will comply with any request granted;
• Request that you be allowed to inspect and copy your health record and billing
record—you may exercise this right by delivering the request in writing to our office;
• Appeal a denial of access to your protected health information except in certain
circumstances;
• Request that your health care record be amended to correct incomplete or
incorrect information by delivering a written request to our office;
• File a statement of disagreement if your amendment is denied, and require that the
request for amendment and any denial be attached in all future disclosures of your
protected health information;
• Obtain an accounting of disclosures of your health information as required to be
maintained by law by delivering a written request to our office. An accounting will not
include internal uses of information for treatment, payment, or operations, disclosures
made to you or made at your request, or disclosures made to family members or friends in
the course of providing care;
• Request that communication of your health information be made by alternative
means or at an alternative location by delivering the request in writing to our office; and,
• Revoke authorizations that you made previously to use or disclose information
except to the extent information or action has already been taken by delivering a written
revocation to our office.
If you want to exercise any of the above rights, please contact [insert name of designated
staff member, phone number, or address], in person or in writing, during normal hours. S
[he] will provide you with assistance on the steps to take to exercise your rights.
Our Responsibilities
The practice is required to:
• Maintain the privacy of your health information as required by law;
• Provide you with a notice of our duties and privacy practices as to the information
we collect and maintain about you;
• Abide by the terms of this Notice;
• Notify you if we cannot accommodate a requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate
health information with you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices
and access practices and to enact new provisions regarding the protected health
information we maintain. If our information practices change, we will amend our
Notice. You are entitled to receive a revised copy of the Notice by calling and
requesting a copy of our "Notice" or by visiting our office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem
regarding the handling of your information, you may contact [insert name, title, and
telephone number of internal contact person].
Additionally, if you believe your privacy rights have been violated, you may file a written
complaint at our office by delivering the written complaint to Dr. Wiggins. You may also
file a complaint by mailing it or e-mailing it to the Secretary of Health and Human
Services whose street address and e-mail address is:
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
www.hhs.gov.
• We cannot, and will not, require you to waive the right to file a complaint with the
Secretary of Health and Human Services (HHS) as a condition of receiving treatment
from the practice.
• We cannot, and will not, retaliate against you for filing a complaint with the
Secretary.
Other Disclosures and Uses
Notification
Unless you object, we may use or disclose your protected health information to notify, or
assist in notifying, a family member, personal representative, or other person responsible
for your care, about your location, and about your general condition, or your death.
Communication with Family
Using our best judgment, we may disclose to a family member, other relative, close
personal friend, or any other person you identify, health information relevant to that
person's involvement in your care or in payment for such care if you do not object or in
an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events
with respect to products and product defects, or post-marketing surveillance information
to enable product recalls, repairs, or replacements.
Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your
protected health information to the extent necessary to comply with laws relating to
Workers Compensation.
Public Health
As required by law, we may disclose your protected health information to public health or
legal authorities charged with preventing or controlling disease, injury, or disability.
Abuse & Neglect
We may disclose your protected health information to public authorities as allowed by
law to report abuse or neglect.
Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution, or its
agents, your protected health information necessary for your health and the health and
safety of other individuals.
Law Enforcement
We may disclose your protected health information for law enforcement purposes as
required by law, such as when required by a court order, or in cases involving felony
prosecutions, or to the extent an individual is in the custody of law enforcement.
Health Oversight
Federal law allows us to release your protected health information to appropriate health
oversight agencies or for health oversight activities.
Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or
administrative proceeding as allowed or required by law, with your consent, or as directed
by a proper court order.
Other Uses
Other uses and disclosures besides those identified in this Notice will be made only as
otherwise authorized by law or with your written authorization and you may revoke the
authorization as previously provided.
Website
We maintain a website that provides information about our entity, this Notice will be on
the website.
ADDITIONAL Uses and Disclosures
Research
• We may disclose 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.
Disaster Relief
• We may use and disclose your protected health information to assist in disaster
relief efforts.
Funeral Directors/Coroners
• We may disclose your protected health information to funeral directors or coroners
consistent with applicable law to allow them to carry out their duties.
Organ Procurement Organizations
• Consistent with applicable law, we may disclose your protected health information
to organ procurement organizations or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose of tissue donation and transplant.
Marketing
• We may contact you to provide you with information about treatment alternatives,
or with information about other health-related benefits and services that may be of
interest to you.
Fund Raising
• We may contact you as part of a fund raising effort.
For Specialized Governmental Functions
• We may disclose your protected health information for specialized government
functions as authorized by law, such as to Armed Forces personnel, for national security
purposes, or to public assistance program personnel.
Effective Date: 7-11-2003
Texas Oral and Facial Surgery, P. A.
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