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(Downlaodable/Printable Version Click Here) Valley
Ear,
Nose
&
Throat
Associates,
PC
Notice
of
Privacy
Practices
Protected
health
information,
about
you,
is
maintained
as
a
record
of
your
contacts
or
visits
for
healthcare
services
with
our
practice.
Specifically,
“protected
health
information”
is
information
about
you,
including
demographic
information
(i.e.,
name,
address,
phone
number,
etc.),
that
may
identify
you
and
relates
to
your
past,
present
or
future
physical
or
mental
health
condition
and
related
health
care
services. Our
practice
is
required
to
follow
specific
rules
on
maintaining
the
confidentiality
of
your
protected
health
information,
using
your
information,
and
disclosing
or
sharing
this
information
with
other
healthcare
professionals
involved
in
your
care
and
treatment.
This
Notice
describes
your
rights
to
access
and
control
your
protected
health
information.
It
also
describes
how
we
follow
applicable
rules
and
use
and
disclose
your
protected
health
information
to
provide
your
treatment,
obtain
payment
for
services
you
receive,
manage
our
healthcare
operations
and
for
other
purposes
that
are
permitted
or
required
by
law. If
you
have
any
questions
about
this
Notice,
please
contact
our
Privacy
Manager. Your
Rights
Under
The
Privacy
Rule
Following
is
a
statement
of
your
rights,
under
the
Privacy
Rule,
in
reference
to
your
protected
health
information.
Please
feel
free
to
discuss
any
questions
with
our
staff. *
You
have
the
right
to
receive,
and
we
are
required
to
provide
you
with,
a
copy
of
this
Notice
of
Privacy
Practices
–
We
are
required
to
follow
the
terms
of
this
notice.
We
reserve
the
right
to
change
the
terms
of
our
notice,
at
any
time.
If
needed,
new
versions
of
this
notice
will
be
effective
for
all
protected
health
information
that
we
maintain
at
that
time,
as
well
as
any
information
we
receive
in
the
future.
Upon
your
request,
we
will
provide
you
with
a
revised
Notice
of
Privacy
Practices.
You
may
call
our
office
and
request
that
a
revised
copy
be
sent
to
you
in
the
mail
or
ask
for
one
at
the
time
of
your
next
appointment.
This
notice
is
also
available
on
our
website,
www.valleyent.info
*
You
have
the
right
to
authorize
other
use
and
disclosure
–
This
means
you
have
the
right
to
authorize
or
deny
any
other
use
or
disclosure
of
protected
health
information
that
is
not
specified
within
this
notice.
You
may
revoke
an
authorization,
at
any
time,
in
writing,
except
to
the
extent
that
your
Healthcare
Provider
or
our
office
has
taken
an
action
in
reliance
on
the
use
or
disclosure
indicated
in
the
authorization. *
You
have
the
right
to
designate
a
personal
representative
–
This
means
you
may
designate
a
person
with
the
delegated
authority
to
consent
to,
or
authorize
the
use
and
disclosure
of
protected
health
information. *
You
have
the
right
to
inspect
and
copy
your
protected
health
information
–
This
means
you
may
inspect
and
obtain
a
copy
of
protected
health
information
about
you
that
is
contained
in
your
patient
record
for
as
long
as
we
maintain
the
protected
health
information.
A
“patient
record”
contains
medical
and
billing
records
and
any
other
records
that
your
physician
and
the
practice
uses
for
making
decisions
about
you. Under
federal
law,
however,
you
may
not
inspect
or
copy
the
following
records:
psychotherapy
notes;
information
compiled
in
reasonable
anticipation
of,
or
use
in,
a
civil,
criminal,
or
administrative
action
or
proceeding;
and
protected
health
information
that
is
subject
to
law
that
prohibits
access
to
protected
health
information.
Depending
on
the
circumstances,
you
have
the
right
to
disagree,
in
writing,
with
the
denial
of
access.
Please
contact
our
Privacy
Manager
if
you
have
questions
about
access
to
your
medical
record. We
have
the
right
to
charge
a
reasonable
fee
for
copies
as
established
by
professional,
state
or
federal
guidelines. *
You
have
the
right
to
request
a
restriction
of
your
protected
health
information
–
This
means
you
may
ask
us,
in
writing,
not
to
use
or
disclose
any
part
of
your
protected
health
information
for
the
purposes
of
treatment,
payment
or
healthcare
operations.
You
may
also
request
that
any
part
of
your
protected
health
information
not
be
disclosed
to
family
members
or
friends
who
may
be
involved
in
your
care
or
for
notification
purposes
as
described
in
this
Notice
of
Privacy
Practices.
Your
request
must
state
the
specific
restriction
requested
and
to
whom
you
want
the
restriction
to
apply. We
are
not
required
to
agree
to
a
restriction
that
you
may
request.
If
we
believe
it
is
in
your
best
interest
to
permit
use
and
disclosure
of
your
protected
health
information,
your
protected
health
information
will
not
be
restricted.
If
your
physician
does
agree
to
the
requested
restriction,
we
may
not
use
or
disclose
your
protected
health
information
in
violation
of
that
restriction
unless
it
is
needed
to
provide
emergency
treatment.
We
have
the
right
to
terminate
a
restriction
and
will
notify
you
in
writing
of
such
terminations.
You
may
disagree
with
our
termination
of
a
restriction
in
written
or
verbal
form.
With
this
in
mind,
please
discuss
any
restriction
you
wish
to
request
with
your
physician.
You
may
request
a
restriction
by
contacting
our
Privacy
Manager. *
You
have
the
right
to
request
an
amendment
to
your
protected
health
information
–
This
means
you
may
request
an
amendment
of
your
protected
health
information
for
as
long
as
we
maintain
this
information.
In
certain
cases,
we
may
deny
your
request
for
an
amendment. *
You
have
the
right
to
request
a
disclosure
accountability
–
This
means
that
you
may
request
a
listing
of
disclosures
that
we
have
made,
of
your
protected
health
information,
to
entities
or
persons
outside
our
office
other
than
for
the
purposes
of
treatment,
payment,
healthcare
operations,
or
a
purpose
authorized
by
you. How
We
May
Use
or
Disclose
Protected
Health
Information
Following
are
examples
of
uses
and
disclosures
of
your
protected
health
information
that
we
are
permitted
to
make.
These
examples
are
not
meant
to
be
exhaustive,
but
to
describe
the
types
of
uses
and
disclosures
that
may
be
made
by
our
office. *
Treatment
–
We
may
use
and
disclose
your
protected
health
information
to
provide,
coordinate,
or
manage
your
healthcare
and
related
services.
This
includes
the
coordination
or
management
of
your
healthcare
with
a
third
party
that
is
involved
in
your
care
and
treatment.
For
example,
we
would
disclose
your
protected
health
information,
as
necessary,
to
a
pharmacy
that
would
fill
your
prescriptions.
We
will
also
disclose
protected
health
information
to
other
Healthcare
Providers
who
may
be
involved
in
your
care
and
treatment. We
may
also
call
you
by
name
in
the
waiting
room
when
your
Healthcare
Provider
is
ready
to
see
you.
We
may
use
or
disclose
your
protected
health
information,
as
necessary,
to
contact
you
to
remind
you
of
your
appointment.
We
may
contact
you
by
phone
or
other
means
to
provide
results
of
exams
or
tests
and
to
provide
information
that
describes
or
recommends
treatment
alternatives
regarding
your
care.
In
addition,
we
may
contact
you
to
provide
information
about
health
related
benefits
and
services
offered
by
our
office. *
Payment
–
Your
protected
health
information
will
be
used,
as
needed,
to
obtain
payment
for
your
healthcare
services.
This
may
include
certain
activities
that
your
health
insurance
plan
may
undertake
before
it
approves
or
pays
for
the
healthcare
services
we
recommend
for
you
such
as;
making
a
determination
of
eligibility
or
coverage
for
insurance
benefits,
reviewing
services
provided
to
you
for
medical
necessity,
and
undertaking
utilization
review
activities. *
Healthcare
Operations
–
We
may
use
or
disclose,
as
needed,
your
protected
health
information
in
order
to
support
the
business
activities
of
our
practice.
This
includes,
but
is
not
limited
to
business
planning
and
development,
quality
assessment
and
improvement,
medical
review,
legal
services
and
auditing
functions.
It
also
includes
education,
provider
credentialing,
certification,
underwriting,
rating,
or
other
insurance-related
activities.
Additionally,
it
includes
business
administrative
activities
such
as
customer
service,
compliance
with
privacy
requirements,
internal
grievance
procedures,
due
diligence
in
connection
with
the
sale
or
transfer
of
assets,
and
creating
de-identified
information. Other
Permitted
and
Required
Uses
and
Disclosures We
may
also
use
and
disclose
your
protected
health
information
in
the
following
instances
as
outlined
below.
You
have
the
opportunity
to
agree
or
object
to
the
use
or
disclosure
of
all
or
part
of
your
protected
health
information. *
To
Others
Involved
in
Your
healthcare
–
Unless
you
object,
we
may
disclose
to
a
member
of
your
family,
a
relative,
a
close
friend
or
any
other
person,
that
you
identify,
your
protected
health
information
that
directly
relates
to
that
person’s
involvement
in
your
healthcare.
If
you
are
unable
to
agree
or
object
to
such
a
disclosure,
we
may
disclose
such
information
as
necessary
if
we
determine
that
it
is
in
your
best
interest
based
on
our
professional judgement.
We
may
use
or
disclose
protected
health
information
to
notify
or
assist
in
notifying
a
family
member,
personal
representative
or
any
other
person
that
is
responsible
for
your
care
of
your
location,
general
condition
or
death.
If
you
are
not
present
or
able
to
agree
or
object
to
the
use
or
disclosure
of
the
protected
health
information,
then
your
Healthcare
Provider
may,
using
professional judgement,
determine
whether
the
disclosure
is
in
your
best
interest.
In
this
case,
only
the
protected
health
information
that
is
relevant
to
your
healthcare
will
be
disclosed. *
As
Required
By
Law
–
We
may
use
or
disclose
your
protected
health
information
to
the
extent
that
is
required
by
law. *
For
Public
Health
–
We
may
disclose
your
protected
health
information
for
public
health
activities
and
purposes
to
a
public
health
authority
that
is
permitted
by
law
to
collect
or
receive
the
information. *
For
Communicable
Diseases
–
We
may
disclose
your
protected
health
information,
if
authorized
by
law,
to
a
person
who
may
have
been
exposed
to
a
communicable
disease
or
may
otherwise
be
at
risk
of
contracting
or
spreading
the
disease
or
condition. *
For
Health
Oversight
–
We
may
disclose
protected
health
information
to
a
health
oversight
agency
for
activities
authorized
by
law,
such
as
audits,
investigations
and
inspections.
Oversight
agencies
seeking
this
information
include
government
agencies
that
oversee
the
healthcare
system,
government
benefit
programs,
other
government
regulatory
programs
and
civil
rights
laws. *
In
Cases
of
Abuse
or
Neglect
–
We
may
disclose
your
protected
health
information
to
a
public
health
authority
that
is
authorized
by
law
to
receive
reports
of
child
abuse
or
neglect.
In
addition,
we
may
disclose
your
protected
health
information
if
we
believe
that
you
have
been
a
victim
of
abuse,
neglect
or
domestic
violence
to
the
government
entity
or
agency
authorized
to
receive
such
information.
In
this
case,
the
disclosure
will
be
made
in
a
manner
that
is
consistent
with
the
requirements
of
applicable
federal
and
state
laws. *
To
The
Food
and
Drug
Administration
–
We
may
disclose
your
protected
health
information
to
a
person
or
company
required
by
the
Food
and
Drug
Administration
to
report
adverse
events,
to
monitor
product
defects
or
problems,
to
report
biologic
product
deviations,
to
track
products,
to
enable
product
recalls,
to
make
repairs
or
replacements,
or
to
conduct
post-marketing
surveillance,
as
required. *
For
Legal
Proceedings
–
We
may
disclose
protected
health
information
in
the
course
of
any
judicial
or
administrative
proceeding,
in
response
to
an
order
of
a
court
or
administrative
tribunal
(to
the
extent
such
disclosure
is
expressly
authorized),
in
certain
conditions
in
response
to
a
subpoena,
discovery
request
or
other
lawful
process. *
To
Law
Enforcement
–
We
may
also
disclose
protected
health
information,
so
long
as
applicable
legal
requirements
are
met,
for
law
enforcement
purposes.
These
law
enforcement
purposes
include:
(1)
legal
processes;
(2)
limited
information
requests
for
identification
and
location
purposes;
(3)
those
pertaining
to
victims
of
a
crime;
(4)
suspicion
that
death
has
occurred
as
a
result
of
criminal
conduct;
(5)
in
the
event
that
a
crime
occurs
on
the
premises
of
the
practice;
and
(6)
medical
emergency
(not
on
the
practice’s
premises)
when
it
is
likely
that
a
crime
has
occurred. *
To
Coroners,
Funeral
Directors
and
Organ
Donation
–
We
may
disclose
protected
health
information
to
a
coroner
or
medical
examiner
for
identification
purposes,
determining
cause
of
death
or
for
the
coroner
or
medical
examiner
to
perform
other
duties
authorized
by
law.
We
may
also
disclose
protected
health
information
to
a
funeral
director,
as
authorized
by
law,
in
order
to
permit
the
funeral
director
to
carry
out
his/her
duties.
Protected
health
information
may
be
used
and
disclosed
for
cadaveric
organ,
eye
or
tissue
donation
purposes. *
For
Research
–
We
may
disclose
your
protected
health
information
to
researchers
when
an
institutional
review
board
has
reviewed
and
approved
the
research
proposal
and
established
protocols
to
ensure
the
privacy
of
your
protected
health
in
formation. *
In
Cases
of
Criminal
Activity
–
Consistent
with
applicable
federal
and
state
laws,
we
may
disclose
your
protected
health
information
if
we
believe
that
the
use
or
disclosure
is
necessary
to
prevent
or
lessen
a
serious
and
imminent
threat
to
the
health
or
safety
of
a
person
or
the
public.
We
may
also
disclose
protected
health
information,
if
it
is
necessary
for
law
enforcement
authorities,
to
identify
or
apprehend
an
individual. *
For
Military
Activity
and
National
Security
–
When
the
appropriate
conditions
apply,
we
may
use
or
disclose
protected
health
information
of
individuals
who
are
Armed
Forces
personnel:
(1)
for
activities
deemed
necessary
by
appropriate
military
command
authorities;
(2)
for
the
purpose
of
a
determination
by
the
Department
of
Veterans
Affairs
of
your
eligibility
for
benefits;
or
(3)
to
foreign
military
authority
if
you
are
a
member
of
that
foreign
military
service. *
For
Workers’
Compensation
–
Your
protected
health
information
may
be
disclosed
as
authorized
to
comply
with
workers’
compensation
laws
and
other
similar
legally
established
programs. *
When
an
Inmate
–
We
may
use
or
disclose
your
protected
health
information
if
you
are
an
inmate
of
a
correctional
facility
and
your
Healthcare
Provider
created
or
received
your
protected
health
information
in
the
course
of
providing
care
to
you. *
Required
Uses
and
Disclosures
–
Under
the
law,
we
must
make
disclosures
about
you
when
required
by
the
Secretary
of
the
Department
of
health
and
human
Services
to
investigate
or
determine
our
compliance
with
the
requirements
of
the
Privacy
Rule. Complaints You
may
complain
to
us
or
to
the
Secretary
of
Health
and
Human
Services
if
you
believe
we
have
violated
your
privacy
rights.
To
file
a
complaint
with
this
office,
please
notify
our
Privacy
Manager.
All
complaints
must
be
submitted
in
writing.
We
will
not
penalize
you
in
any
way
for
filing
a
complaint. Form effective 4/14/03 |
||
