Effective Date: April 14, 2003

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.

If you should have any questions about this notice, please contact:
Teri Ogburn, Privacy Officer at 903-614-3102.

WHO WILL FOLLOW THIS NOTICE?

• Any health care professional who is authorized to enter or retrieve information into your clinic records.
• All employees of the clinic.
• All departments of Collom and Carney Main Clinic and satellite locations: Behavioral Medicine, Urology Center, Richmond Road, Westside, Eye Institute, New Boston, Prescott, and Ashdown. All these locations follow the terms of this notice. In addition these locations share medical information with each other for treatment, payment or clinic operations purposes described in this notice.

We understand that medical information about you and your health is personal and we are committed to protecting this information. We create a record of the care and services you receive at the clinic. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the clinic.

This notice will tell you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information.

WE ARE REQUIRED BY LAW TO:

• Make sure that medical information that identifies you is kept private;
• Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of this notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU?

The following categories describe different ways that we may use and disclose medical information. We will explain what we mean and give some examples for each category of uses or disclosures. It is not possible to list every use or disclosure in each category. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• 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, nursing students, or other clinic personnel who are involved in your care. For example if your doctor is going to do surgery on you for he may want to know he may want to know if you have any heart problems. Different departments of the clinic also may share information about you in order to coordinate the different things you need, such as lab work, x-rays or prescriptions. We may also disclose medical information to people outside of the clinic, who may be involved in your medical care such as hospital personnel, home health agencies or other providers or agencies we use to provide services that are part of your care.
• For Payment. We may use and disclose medical information about you so that the treatment and services you receive at the clinic may be billed and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information on the surgery that one of our surgeons did so your health plan will pay us for the surgery. We may also tell your health plan about a treatment or procedure you are going to receive to obtain prior approval or to determine whether your plan will cover the services.
• For Health Care Operations. We may use and disclose medical information about you for clinic operations. These uses and disclosures are necessary to run the clinic in an efficient manner and insure that all of our patients receive quality care. For example, medical records are audited for timely documentation and correct billing. We may also combine the medical information we have with other medical information from other clinics to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so that health care and health care delivery can be studied and improved without learning who the specific patients are.
• Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment at the clinic. For example, a reminder that your next appointment with a certain physician is coming up.
• Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects however are subject to a special approval process. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We will almost all ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care.
• As Required By Law. We will disclose medical information about you when required to do so by federal, state, or local law.
• To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent or resolve the threat.

SPECIAL SITUATIONS

• Organ and Tissue Donation. Where you have signed an organ donation card, or have otherwise formally indicated that you are an organ donor, we may release medical information to organizations that handle procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ tissue donation and transplantation.
• Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities.
• Workers' Compensation. We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
• Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
  • To prevent or control disease, injury or disability;
  • To report births and deaths;
  • To report child abuse or neglect;
  • To report reactions to medications or problems with products;
  • To notify people of recalls of products they may be using;
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
  • To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
• Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court order or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
• Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
  • About a death we believe may be the result of criminal conduct.
  • In an emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
• Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner when necessary. For example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the clinic to funeral directors as necessary to carry out their duties.
• Inmates. If your are an inmate of a correctional facility or under the custody of a law enforcement official, we may release medical information about you to the correctional facility or law enforcement official. This release would be necessary (1) for the facility to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional facility.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

You have the following rights regarding medical information we collect and maintain about you:

• Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
  
  To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Teri Ogburn, Director, Health Information Management. If you request a copy of the information we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
  
  We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the clinic will review your request and denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
  
• Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by the clinic.
  
  To request an amendment, your request must be made in writing and submitted to Teri Ogburn, Director, Health Information. In addition, you must provide a reason that supports your request.
  
  We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we deny your request if you ask us to amend information that:
  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by the clinic;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.
• Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures". This is a list of the disclosures we made of your medical information.
  
  To request this list you must submit your request in writing to Teri Ogburn, Director, Health Information Management. Your request must state a time period which may not be longer then six years and may not include dates before February 26, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists within the 12 month period, we may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
  
• Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care.
  
  We are not required to agree to your request. If we do, we will comply with your request unless the information is needed to provide you emergency treatment.
  
  To request restrictions you must make your request in writing Teri Ogburn, Privacy Officer. In your request you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
  
• Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example you can ask that we only contact you at work or by mail.
  
  To request confidential communications or a change to an already existing request, you must make your request in writing to Teri Ogburn, Privacy Officer. You do not have to state a reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

CHANGES TO THIS NOTICE.

We reserve the right to change this notice. Re reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. The effective date of the notice will be on the first page.

COMPLAINTS.

If you believe your privacy rights have been violated, you may file a complaint with the clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with the clinic, contact:

Teri Ogburn, Privacy Office / Director HIM
903-614-3286

All complaints should be submitted in writing.
You will NOT be penalized for filing a complaint.