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[Patient Intake Forms]
MASSACHUSETTS E.N.T. ASSOCIATES, INC.
NOTICE OF PATIENT PRIVACY PRACTICES
EFFECTIVE 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
If you have any questions about this Notice, please contact our Privacy
Officer at the number listed at the end of this Notice.
Each time you visit a healthcare provider, a record of your visit is made.
Typically, this record contains your symptoms, examination and test results,
diagnoses, treatment, a plan for future care or treatment, and billing-related
information. This Notice applies to all of the records of your care generated by
your health care provider.
Massachusetts E.N.T. Associates, Inc. is required by law to maintain the
privacy of your health information and to provide you with a description of our
legal duties and privacy practices regarding your health information. The
current Notice will be posted in the main reception room and on our website at
www.massentassoc.com. The notice will include the effective date. In addition,
we will make our best effort to provide you with a copy of this notice that we
request you acknowledge with your signature.
We are required by law to abide by the terms of this Notice and notify you if
we make changes to this Notice, which may be at any time. Changes to the Notice
will apply to your medical information that we already maintain as well as new
information received after the change occurs. If we change our Notice, it will
be posted in the main reception room and on our website at www.massentassoc.com.
You may also request that a revised Notice be sent to you in the mail or
you may ask for one at your next appointment or appropriate visit. This Notice
will also serve to advise you as to your rights with regard to your medical
How We May Use and Disclose Medical Information About You.
The following categories describe examples of the way we use and disclose
1. For Treatment: We may use medical information about you to
provide, coordinate and manage your treatment or services. We may disclose
medical information about you to other doctors, nurses, technicians (e.g.
clinical laboratories or imaging companies), medical students, or other
personnel who are involved in your care. We may communicate your information
either orally or in writing by mail or facsimile.
We may also provide a subsequent healthcare provider with copies of various
reports that should assist him or her in treating you. For example, your
medical information may be provided to a physician to whom you have been
referred so as to ensure that the physician has appropriate information
regarding your previous treatment and diagnosis.
2. For Payment: We may use and disclose medical information
about your treatment and services to bill and collect payment from you, your
insurance company or a third party payer. For example, we may need to give
your insurance company information before it approves or pays for the health
care services we recommend for you
3. For Health Care Operations: We may use or disclose, as
needed, your health information in order to support our business activities.
These activities may include, but are not limited to quality assessment
activities, employee review activities, licensing, legal advice, accounting
support, information systems support and conducting or arranging for other
business activities. In addition, we may also call you by name in the waiting
room when your physician 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 by telephone or reminder card.
Business Associates: There are some services provided in our
organization through contracts with business associates. Examples include
computer hardware and software support, transcription service and shredding.
When these services are contracted, we may disclose your health information to
our business associate so that they can perform the job that we have asked
them to do and bill you or your third-party payer for services rendered. To
protect your health information, however, we require the business associate to
appropriately safeguard your information through a written contract.
Other Permitted and Required Uses and Disclosures That May Be Made With Your
Consent, Authorization or Opportunity to Object
We also may use and disclose your health information as set forth below. You
have the opportunity to agree or object to the use or disclosure of all or part
of your health information in these instances. If you are not present or able to
agree or object to the use or disclosure of the health information (such as in
an emergency situation), then your clinician may, using professional judgment,
determine whether the disclosure is in your best interest. In this case, only
the information that is relevant to your health care will be disclosed.
1. Individuals Involved in Your Care or Payment for Your Care:
Unless you object, we may release medical information about you to a friend or
family member who is involved in your medical care or who helps to pay for
your care. In addition, we may disclose medical information about you to an
entity assisting in a disaster relief effort so that your family can be
notified about your condition, status and location.
2. Future Communications: We may communicate to you via
newsletters, mailings or other means regarding treatment options, information
on health-related benefits or services; to remind you that you have an
appointment for medical care; or other community based initiatives or
activities in which our facility is participating. If you are not interested
in receiving these materials, please contact our Privacy Officer.
Other Permitted and Required Uses and Disclosures That May Be Made Without
Your Authorization or Opportunity to Object
We may use or disclose your health information in the following situations
without your authorization or without providing you with an opportunity to
object. These situations include:
1. As required by law. We may use and disclose health
information to the following types of entities, including but not limited
· Food and Drug Administration
· Public Health or Legal Authorities charged with preventing or
controlling disease, injury or disability
· Correctional Institutions
· Workers Compensation Agents
· Organ and Tissue Donation Organizations
· Military Command Authorities
· Health Oversight Agencies
· Funeral Directors, Coroners and Medical Directors
· National Security and Intelligence Agencies
· Protective Services for the President and Others
· Authority that receives reports on abuse and neglect
2. Law Enforcement/Legal Proceedings: We may disclose
health information for law enforcement purposes as required by law or in
response to a valid subpoena.
3. State-Specific Requirements: Many states have
requirements for reporting, including population-based activities relating
to improving health or reducing health care costs.
Your Health Information Rights
Although your health record is the physical property of the Massachusetts
E.N.T. Associates, Inc. that compiled it, you have the right to:
1. Inspect and Copy: You have the right to inspect and copy
medical information that may be used to make decisions about your care. We
ask that you submit these requests in writing. Usually, this includes
medical and billing records, but does not include psychotherapy notes or
information compiled in reasonable anticipation of, or for use in, a civil,
criminal, or administrative action or proceeding. 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.
The person conducting the review will not be the person who denied your
request. We will comply with the outcome of the review. Requests for access
to and copies of your medical information must be submitted to Massachusetts
E.N.T. Associates, Inc. in writing. The practice may charge up to $20.00 per
hour for clerical time and 25 cents per page for copies of medical records
2. Amend: If you feel that medical information we have
about you is incorrect or incomplete, you may ask us to amend the
information by submitting a request in writing. You have the right to
request an amendment for as long as we keep the information. We may deny
your request for an amendment and if this occurs, you will be notified of
the reason for the denial.
3. An Accounting of Disclosures: You have the right to
request an accounting of our disclosures of medical information about you
except for certain circumstances, including disclosures for treatment,
payment, health care operations or where you specifically authorized a
disclosure. Massachusetts E.N.T. Associates, Inc. will provide the first
accounting to you in any 12-month period without charge. The cost for
subsequent requests for an accounting within the 12-month period will be
$10.00. We ask that you submit these requests in writing.
4. 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,
like a family member or friend. For example, you could ask that we not use
or disclose information about a procedure that you had. We ask that you
submit these requests in writing.
We are not required to agree to your request. If we do agree, we
will comply with your request unless the information is needed to provide
you with emergency treatment.
5. 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. We will agree to the request to the extent
that it is reasonable for us to do so. For example, you can ask that we use
an alternative address for billing purposes. We ask that you submit these
requests in writing.
6. A Paper Copy of This Notice: You have the right to a
paper copy of this notice. You may ask us to give you a copy of this notice
at any time. Even if you have agreed to receive this notice electronically,
you are still entitled to a paper copy of this notice.
To exercise any of your rights, please obtain the required forms from the
Privacy Officer and submit your request in writing.
If you believe your privacy rights have been violated, you may file a
complaint with us by calling 978-256-5557 X113 and asking for the Privacy
Officer or by contacting the Secretary of the Federal Department of Health and
Human Services. All complaints must be also submitted in writing. You will not
be penalized for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this Notice
or the laws that apply to us will be made only with your written permission. If
you provide us permission to use or disclose medical information about you, you
may revoke that permission, in writing, at any time. If you revoke your
permission, we will no longer use or disclose medical information about you for
the reasons covered by your written authorization. However, we are unable to
take back any disclosures we have already made with your permission and we are
required to retain our records of the care that we provided to you.
Privacy Officer: Sheryl Heffernan
Telephone Number: 978-256-5557 x113