NOTICE OF MEDICAL INFORMATION PRIVACY RIGHTS

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.

During your treatment at Ear, Nose & Throat SpecialtyCare, doctors, nurses and other caregivers may gather information about your medical history and your current health. This notice will explain how much information may be used and shared with others. It will also explain your privacy rights regarding this kind of information.

Your medical information will be used and disclosed for the following purposes:

  • Treatment: We will use your information to provide, coordinate, and manage your care and treatment. For example, one of our clinic physicians may share your medical information with another physician for a consultation or a referral.
  • Payment: We will use your information to receive payment for the services we provide. For example, we will disclose information in order to submit the bill or claim to insurance companies and/or Medicare or Medicaid.
  • Health Care Operations: We will use your information for certain activities related to the function of our clinic. For example, we may use or disclose information for quality assurance activities, legal services, underwriting, and other business management and administrative activities.
  • Appointment Reminders and Other Health Information: We may use your medical information to send you reminders about future appointments. Your medical information may also be used to provide you with information about new or alternative treatments or other health care services.

Ear, Nose & Throat SpecialtyCare may also use or disclose your information for the following purposes:

  • To people who will be taking care of you or helping to pay your medical bills, such as family members or close friends. Ear, Nose & Throat SpecialtyCare will only disclose medical information that these people need to know. We may also use your medical information to let family members or other responsible people know where you are and what your general medical condition is. If you are able to make your own health care decisions, our clinic will ask your permission before using your medical information for these purposes. If you are unable to make health care decisions, our clinic will disclose relevant medical information to family members or other responsible people if we feel it is in your best interest to do so. For example, we may provide limited medical information to allow a family member to pick up a prescription or x-ray for you.
  • Under emergency conditions, to government or other groups that assist in emergencies or disasters.
  • Our clinic also may disclose or use your information without your consent in the following cases: when required by law; for public health activities; relating to victims of abuse/neglect/domestic violence, if required/authorized by law and/or if you agree; for health oversight activities; for judicial and administrative proceedings to the extent permitted by law; for law enforcement purposes, as permitted or required by law; to coroners/medical examiners/funeral directors, as permitted by law; for organ donation purposes; for research purposes under certain circum-stances; to avert a serious threat to health or safety; for certain specialized government functions, such as military discharge, and national security and intelligence; and for workers’ compensation purposes.

Ear, Nose & Throat SpecialtyCare will not use or disclose your information in any other way unless you allow us to do so in writing. If you do give us permission to use or disclose your medical information for another purpose, you may have the right to change your mind and revoke the permission at any time.

Privacy Rights:

  • You may request that the clinic not use your medical information in certain ways or for certain purposes. You may also request that our clinic not provide your medical information to certain people. However, the clinic has the right to refuse your request, and the clinic may use or disclose your medical information in situations requiring emergency treatment, in which case we will ask the person(s) who receive the information not to further use or disclose the information.
  • You may request the clinic provide you with your medical information in a confidential manner. For example, you can request that we send your appointment reminders, bills and other mailings to different address or that we notify you of this kind of information in another way, such as a phone call. You must make this request in writing and specify another address or means of communication. We may also ask you to give us information on how you will pay your bills.
  • You may ask to see and copy your medical records, unless the information is protected by law. You must make these requests in writing. If your request to look at or copy your medical records is denied, you have to the right to have the denial reviewed by a health care professional. We will act upon your request within 30 days, and we may charge you a legally acceptable amount for copying costs.
  • You may ask to change information in your medical records. If your request is denied, you can write a statement of disagreement with the denial that we will keep with your medical information.
  • You may ask us to provide you with information about certain disclosures of your medical information in the past. You may request an accounting of disclosures made in the six years, but this accounting will only cover disclosures made after April 14, 2003.
  • If you feel your medical information privacy rights have been violated, you may file a complaint with the Secretary of Health and Human Services and/or with Ear, Nose & Throat SpecialtyCare contact person listed below. Filing a complaint will not affect the quality of your services you receive at our clinic and you will not be retaliated against for filing a complaint.
  • You must contact the designated privacy official at the clinic:
    HIPAA Officer 2211 Park Avenue South, Minneapolis, MN 55404 (612) 871-1144

The effective date of this notice is April 14, 2003. Ear, Nose & Throat SpecialtyCare is required by law to maintain the privacy of protected health information and to provide individuals with this notice of its legal duties and privacy practices with respect to health information. Our clinic is required to abide by the terms of the notice currently in effect. Our clinic reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information maintained by our clinic. If the terms of this notice are changed, Ear, Nose & Throat SpecialtyCare will provide individuals with a revised notice upon request and by posting the revised notice in designated locations at Ear, Nose & Throat SpecialtyCare

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