NOTICE OF PRIVACY PRACTICESTHIS 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.This notice takes effect on April 14, 2003 and remains in effect until further notice.1. OUR PLEDGE REGARDING MEDICAL INFORMATIONThe privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our medical practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.2. OUR LEGAL DUTYLaw Requires Us to1.Keep your medical information private.2.Document who has access and how they receive it.3.Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.We Have the Right to1.Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.2.Make the changes in our privacy practices, and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.Notice of Change to Privacy Practices1.Before we make an important change in our privacy practices, we will change this notice and make the new notice available.3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATIONThe following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice.FOR TREATMENT We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you.FOR PAYMENT We may use and disclose your medical information for payment purposes. A bill may be sent to you or a thirdparty payer. The information on or accompanying the bill may include your medical information.FOR HEALTH CARE OPERATIONS We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you. Notifying you by phone, fax or mail in regards to any information you may need, such as lab results, diagnostic results, and other diagnostic procedures will be done with your approval and personalized list of recipients. ADDITIONAL USES AND DISCLOSURES In addition to using and disclosing your medical information for treatment, payment and health care operations, we may use and disclose medical information for the following purposes.Notification We may use and disclose medical information to notify or help notify a family member, your personal representative or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, xray or medical information for you.Disaster Relief We may share medical information with a public or private organization or person who can legally assist in disaster relief efforts.Research in Limited Circumstances We may use medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information.Funeral Director, Coroner, Medical Examiner To help them carry out their duties, we may share the medical information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.Specialized Government Functions Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, or for protective services for the President and others for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.Court Orders and Judicial and Administrative Proceedings We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. We may share the medical information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.Public Health Activities As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.Workers Compensation We may disclose health information when authorized or necessary to comply with laws relating to workers compensation or other similar programs.Health Oversight Activities We may disclose medical information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.Law Enforcement Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws such as the reporting of certain types of wounds, pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.Appointment Reminders We may use and disclose medical information for purposes of sending you appointment postcards or otherwise reminding you of your appointments.Alternative and Additional Medical Services We may use and disclose medical information to furnish you with information about healthrelated benefits and services that may be of interest to you, and to describe or recommend treatment alternatives.4. YOUR INDIVIDUAL RIGHTS 1.Request copies of certain parts of your medical information. You may request that we provide copies in a copy format only. You must make your request in writing. You may get the form to request access by using the contact information listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice. If you request copies, we may charge you a small fee for each page and postage if you want the copies mailed to you. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.2.Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions.3.Request that we place additional restrictions on our use or disclosure of our medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement except in the case of an emergency.4.Request that we communicate with you about your medical information by different means or to different locations. Your request that we communicate your medical information to you by different means or at different locations must be made in writing to location listed at the end of this notice.5.Request that we change certain parts of your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.6.If you have received a paper copy of these notices, you have the right to obtain an additional copy by making a request in writing to the contact person listed at the end of this notice.QUESTIONS AND COMPLAINTSIf you have any questions about this notice or if you think that we may have violated your privacy rights, please contact us. You may also submit a written complaint to the U.S. Department of Health and Human Services. You may contact us to submit a complaint or submit requests involving any of your rights in Section 4 of this notice by writing to the following addressNorthEast Tarrant Internal Medicine amp Associates, PA,LLP469 WEstpark Way 479 Westpark WayEuless, Tx 76040 Euless, Tx 76040817 2832888 817358 5500 We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint. PRIVACY PRACTICES ACKNOWLEDGEMENTACKNOWLEDGEMENT FORMI have received the Notice of Privacy Practices and I have been provided an opportunity to review it.Name____________________________________________________Birthdate______________________Signature______________________________________________________________________________Date__________________________________________________________________________________