CHARLES H. RAILSBACK, M.D., P.A.

JOHN C. PONDER, M.D.

JAMES D. GONZALES, M.D.

PETER T. JANICKI, M.D.

NATALIE A. ROBERGE, M.D.

COURTNEY A. NOELL, M.D.

TIMOTHY F. RAGSDALE, M.D.

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TERMS OF USE

Privacy Policy

NOTICE OF PRIVACY PRACTICES
(Revised 06/27/03)

Please read this notice carefully and sign the attached acknowledgement, which will be retained in your medical chart. This notice is being provided to you, as mandated by the Health Insurance Portability and Accountability Act (HIPAA).

INTRODUCTION

At Texas Ear, Nose and Throat Specialists, L.L.P. we are committed to treating and using protected health information about you responsibly. This Notice describes how and when we use or disclose your personal information. It also describes your rights as they relate to your protected health information. This Notice is effective April 14, 2003 and applies to all protected health information as defined by federal and state regulations.

A. TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS:

TREATMENT: We will use your health information for treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosis of medical condition, and providing treatment. When we provide treatment we may request that your primary care physician share your medical information with us. We may provide your primary care physician with information about your particular condition so he or she can appropriately treat you for other medical conditions. For example: results of laboratory tests and procedures will be available in your medical record to all health professionals who may be involved in your health care.

PAYMENT: We will use your information for payment. Your health plan will request and receive information on dates of service, the services provided and the medical condition being treated in order to pay for the service rendered.

HEALTHCARE OPERATIONS: We will use your information for regular health operations. Your health information may be used as necessary to support the day-to-day activities and management of Texas Ear, Nose and Throat Specialists, L.L.P. For example: Texas Ear, Nose and Throat Specialists, L.L.P. may engage the services of a professional to aid this practice in its compliance programs. This person could review billing and medical files to ensure we maintain our compliance with regulations and the law. Texas Ear, Nose and Throat Specialists, L.L.P. may request a business associate to review charts, medical records, and physician activities to evaluate and improve the quality of healthcare provided.  Some examples of these "business associates" are an accounting firm, consulting service, billing service, collection agency, transcription service, answering services and computer software/hardware providers.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.  We may release your medical information when law requires the disclosure. 

For any situation other than those stated above you would be required to sign an authorization and/or consent to use or disclose any identifiable health information about you. You can submit a written revocation of an authorization and/or consent to stop future use and disclosure. However, your decision to revoke the authorization and/or consent will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.  A revocation will not apply to any disclosures or uses already made or that rely on an authorization and/or consent.

B.  YOUR RIGHTS UNDER FEDERAL LAW

You have certain rights under (HIPAA) Health Insurance Portability and Accountability Act. These regulations create several privileges that patients may exercise. We will not retaliate against patients who exercise their HIPAA rights.
These privileges include:

• The right to request restrictions on the use and disclosure of your protected health information. In regard to your right to request a restriction or limit on how your health information is disclosed for treatment, payment, or healthcare operations, we do NOT have to agree to this restriction, but if we agree, we will comply with your request, except under emergency circumstances. You may also request that we limit disclosure to a family member, other relatives, or close personal friends who may or may not be involved in your care. Please submit the following in writing:
  • The information to be restricted. 
  • What kind of restrictions you are requesting.
  • To whom these limits apply.
• The right to receive confidential communications by alternative means or to an alternative location concerning your medical condition and treatment. If you want to request that we communicate with you via an alternative means and/or an alternative location, please specify in your correspondence exactly how you want us to communicate with you and, if you are directing us to send it to a particular place, the contact/address information.
• The right to inspect and copy your protected health information. If you request to inspect or copy your health information, Texas law requires the request be made in writing and that you allow us 15 days from the date of your request to provide the copies at a reasonable cost-base fee. We will inform you when the records are ready or if we believe that access should be limited. We may ask that a narrative of that information be provided rather than copies. However, if you do not agree to our request, we will provide copies. We can refuse to provide some information based on certain criteria (please contact the person noted at the end of this document for further information).
• The right to amend or submit corrections to your protected health information. If you request an amendment to your health information you will allow us 60 days from the date of your written request. We can refuse to allow your request for an amendment based on certain criteria (please contact the person noted at the end of this document for further information). We will inform you in writing of approval or refusal to an amendment. If we refuse to allow an amendment, you are permitted to include a patient statement about the information at issue in your medical record.
• The right to receive an accounting of how and to whom your protected health information has been disclosed. Your first request for an accounting of disclosures (within a 12 month period) will be at no charge. For additional requests within that period we are permitted to charge for the cost of creating that list.
• The right to receive a printed copy of this notice.

The above requests must be made in writing to the person listed at the end of this document.

C. APPOINTMENT REMINDERS, TREATMENT ALTERNATIVES, OTHER BENEFITS AND PATIENT COMMUNICATION:

The practice may use your information to provide appointment reminders, information about treatment alternatives, or health-related benefits and services that may be of interest to you. Typically the above information will be sent on postcards via mail, or, a brief non-specific message may be left on your answering machine. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician.  You may also be called by name in the waiting room when your physician is ready to see you.

D.  FOR MORE INFORMATION, COPIES OF REVISIONS OR TO REPORT A COMPLAINT:

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal, state laws and regulations. Whatever the reason for these revisions, we will post any revised notice in the office where it can be seen. You can request a paper copy at any time. The revised policies and practices will be applied to all protected health information that we maintain.
If you have complaints, questions or would like additional information regarding this notice or the privacy practices of Texas Ear, Nose and Throat Specialists, L.L.P., please contact:

David Guier 
Texas Ear, Nose and Throat Specialists, L.L.P.
1615 Hospital Parkway Suite 210
Bedford, Texas 76022
817-540-3121

If you believe that your privacy rights have been violated, please contact the aforementioned practice Privacy Official, or you may file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the practice's Privacy Official or with the Office for Civil Rights.
The address for the Office for Civil Rights is listed below:

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

Return Policy

In the event a credit balance has resulted from a cancelled surgery, an insurance payment greater than estimated, or for some other reason except for a hearing aid return we will make every effort to refund the balance within 10 business days.  Where an economic hardship is involved we will expedite the refund upon the request of the patient or responsible party.