Notice of Privacy Practices

This Notice of Privacy Practices describes the ways in which medical information about you may be used and disclosed, and how you can obtain access to it. Please review it carefully.

• Understanding your Health Information

• Your Rights

• Our Responsibilities

• Uses and Disclosures of Health Information without Authorization

• Disclosures Requiring Verbal Agreement

• Disclosures Required by Law or otherwise Allowed without Authorization or Notification

• Uses and Disclosures Requiring Authorization

• Entity Privacy Officer Contacts

Understanding Your Health Information

Each time you visit a physician, or other health care provider, a record of your visit is made in order to manage the care you receive. We understand that the medical information that is recorded about you and your health is personal. The confidentiality of your health information is also protected under both state and federal law.

This Notice of Privacy Practices describes the ways that Arlington Physicians, P.A. may use and disclose your information and the rights that you have regarding your health information. The Notice applies to all facilities.

Your Health Information Rights

Although your health information is the physical property of the facility or practitioner that compiled it, the information belongs to you, and you have certain rights over that information. You have the right to:

• Request, in writing, a restriction on certain uses and disclosures of your health information. However, agreement with the request is not required by law, such as when it is determined that compliance with the restriction cannot be guaranteed.
• Inspect or obtain a copy of your health record as provided by law.
• Request, in writing, that your health record be amended as provided by law, if you feel the health information we have about you is incorrect or incomplete. You will be notified if the request cannot be granted.
• Request that we communicate with you about your health information in a specific way or at a specific location. Reasonable requests will be accommodated.
• Obtain an accounting of disclosures of your health information as provided by law.
• Obtain a paper copy of this Notice of Privacy Practices on request.

You may exercise these rights by directing a request to the Privacy Contact listed on this Notice.

Our Responsibilities

Arlington Physicians, P.A. has certain responsibilities regarding your health information, including the requirement to:

• Maintain the privacy of your health information.
• Provide you with this Notice that describes Texas Health's legal duties and privacy practices regarding the information that we maintain about you.
• Abide by the terms of the Notice currently in effect.

We reserve the right to change these information privacy policies and practices and to make the changes applicable to any health information that we maintain. If changes are made, the revised Notice of Privacy Practices will be made available at each facility, posted on our website, and will be supplied when requested.

Uses and Disclosures of Health Information without Authorization

When you obtain services certain uses and disclosures of your health information are necessary and permitted by law in order to treat you, to process payments for your treatment and to support the operations of the entity and other involved providers. The following categories describe ways that Texas Health entities use or disclose your information, and some representative examples are provided in each category. All of the ways your health information is used or disclosed should fall within one of these categories.

Your health information will be used for treatment
Example: Disclosures of medical information about you may be made to doctors, nurses, technicians, medical residents or others who are involved in taking care of you. This information may be disclosed to other physicians who are treating you or to other health care facilities involved in your care. Information may be shared with pharmacies, laboratories or radiology centers for the coordination of different treatments.

In addition, if you receive treatment from a Texas Health entity that participates in a health information exchange, the entity may share your health information with the health information exchange in an information system for the purposes of diagnosis and treatment. Other health care providers may access your health information through this system as part of your treatment.

Your health information will be used for payment.
Example: Health information about you may be disclosed so that services provided to you may be billed to an insurance company or a third party. Information may be provided to your health plan about treatment you are going to receive in order to obtain prior approval or to determine if your health plan will cover the treatment.

Your health information will be used for health care operations.
Example: The information in your health record may be used to evaluate and improve the quality of the care and services we provide. Students, volunteers, and trainees may have access to your health information for training and treatment purposes as they participate in continuing education, training, internships, and residency programs.

Business Associates
There are some services that we provide through contracts with third party business associates. Examples include transcription agencies and copying services. To protect your health information, Texas Health entities require these business associates to appropriately protect your information.

Continuity of Care
In order to provide for the continuity of your care your information may be shared with other health care providers such as home health agencies. Information about you may be disclosed to community services agencies in order to obtain their services on your behalf.

Disclosures Requiring Verbal Agreement

Unless you give notice of an objection, and in accordance with your Authorization to Verbally Release Health Information, medical information may be released to a family member or other person who is involved in your medical care or who helps pay for your care. Information about you may be disclosed to notify a family member, legally authorized representative or other person responsible for your care about your location and general condition. This may include disclosures of information about you to an organization assisting in a disaster relief effort, such as the American Red Cross, so that your family can be notified about your condition.

Disclosures Required by Law or otherwise Allowed without Authorization or Notification

The following disclosures of health information may be made according to state and federal law without your written authorization or verbal agreement:

• When a disclosure is required by federal, state or local law, judicial or administrative proceedings, or for law enforcement. Examples would be reporting gunshot wounds or child abuse, or responding to court orders.
• For public health purposes, such as reporting information about births, deaths, and various diseases, or disclosures to the FDA regarding adverse events related to food, medications or devices.
• For health oversight activities, such as audits, inspections or licensure investigations.
• To organ procurement organizations for the purpose of tissue donation and transplant.
• For research purposes, when the research has been approved by an institutional review board that has reviewed the research proposal and established guidelines to provide for the privacy of your health information; or the disclosure is that of a limited data set, where personal identifiers have been removed.
• To coroners and funeral directors for the purpose of identification, the determination of the cause of death, or to perform their duties as authorized by law.
• To avoid a serious threat to the health or safety of a person or the public.
• For specific government functions, such as protection of the president of the United States.
• For workers' compensation purposes.
• To military command authorities as required for members of the armed forces.
• To authorized federal officials for national security and intelligence activities as authorized by law.
• To correctional institutions or law enforcement officials concerning the health information of inmates, as authorized by law.

Other Allowable Uses and Disclosures without Authorization
Other uses or disclosures of your health information that may be made include:

• Contacting you to provide appointment reminders for treatment or medical care, as well as to recommend treatment alternatives.
• Notifying you of health-related benefits and services that may be of interest to you.

Required Uses and Disclosures
Under the law we must make disclosures when required by the secretary of the Department of Health and Human Services to investigate or determine our compliance with federal privacy law.

Uses and Disclosures Requiring Authorization
Any other uses or disclosures of your health information not addressed in this notice or otherwise required by law will be made only with your written authorization. You may revoke such authorization at any time.

Privacy Complaints
You have the right to file a complaint if you believe your privacy rights have been violated. The complaint may be addressed to the privacy contact listed in this notice, or to the secretary of the Department of Health and Human Services. There will be no retaliation for registering a complaint.

Privacy Contact
Address any questions about this notice or how to exercise your privacy rights to the applicable privacy officer contact listed below.

Effective Date
July 16, 2007

Entity Privacy Officer Contacts
Privacy Officer
Arlington Physicians, P.A.
P.O. Box 120069
Arlington, TX 76012

You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government on us. The contact information for the United States Department of Health and Human Services is:

U.S. Department of Health and Human Services
HIPAA Complaint
7500 Security Blvd., C5-24-04
Baltimore, MD 21244