NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES

DENVER ALLERGY AND ASTHMA ASSOCIATES, P.C. (“DAA”) is required to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices.  DAA will not use or disclose your health information except as described in this Notice.  This Notice applies to all of the medical records generated by the DAA, as well as records we receive from other providers.

Uses and Disclosures Requiring Your Consent:  With your consent, DAA may use and disclose your health information for the following purposes.

Treatment:  DAA may use your health information in the provision and coordination of your healthcare.  We may disclose all or any portion of your medical record information to your attending physician, consulting physician(s), nurses, technicians, medical students, and other health care providers who have a legitimate need for such information in your care and treatment. Different departments may share medical information about you in order to coordinate specific services, such as prescriptions, lab work and x-rays.  DAA also may disclose your health information to people outside DAA who may be involved in your medical care after you leave DAA, such as family members, clergy and others used to provide services that are part of your care.  Other ways we may use or disclose your health information for purposes related to treatment are:

·         Treatment Alternatives:  To tell you about or recommend possible treatment options or alternatives that may be of interest to you.

·         Appointment Reminders:  To contact you as a reminder that you have an appointment for treatment or medical care at the DAA.

·         Health Related Business and Services:  To tell you of health-related benefits or services that may be of interest to you.

Payment:  DAA may release health information about you for the purposes of determining coverage, billing, claims management, medical data processing, and reimbursement.  The information may be released to an insurance company, third party payer or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record which are necessary for payment of your account.  For example, a bill sent to a third party payer may include information that identifies you, your diagnosis, and the procedures and supplies used.

Routine Healthcare Operations:  DAA may use and disclose your health information during routine healthcare operations, including quality assurance, utilization review, medical review, internal auditing, accreditation, certification, licensing or credentialing activities of DAA, medical research and educational purposes.  DAA may engage outside companies to carry certain aspects of routine healthcare operations.  These entities are called the  “business associates” of DAA.  DAA may need to disclose your health information to the business associates to allow them to perform their duties.  The business associates will, in turn, use and disclose your health information as they conduct business on the DAA behalf.  Examples of business associates, include, but are not limited to, consultants, accountants, lawyers, medical transcriptionists and third-party billing companies.  DAA requires the business associate to protect the confidentiality of your medical information.

·         Marketing:  To disclose certain contact information to a third party to provide marketing materials and information to you.

Uses and Disclosures Requiring Your Authorization:  The DAA may not disclose your health information to persons outside of the DAA for purposes other than treatment, payment or healthcare operations without your authorization.  In addition, the DAA may not use or disclose psychotherapy notes written by your mental health provider, if any, without your authorization, even for treatment, payment or healthcare operations.  You have the right to revoke any authorization you have previously given by submitting a written statement of revocation to the DAA. 

Uses and Disclosures to Which You May Object: 

Family/Friends:  DAA may disclose your health information to a friend or family member who is involved in your medical care.  We may also give information to someone who helps pay for your care.  For example, we may also tell your family or friends of your condition and that you are in the Hospital.  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.  If you have any objection to the use and disclosure of your health information in this manner, please tell us.

Uses and Disclosures that are Required or Permitted Without Consent or Authorization

Research:  Under certain circumstances, DAA may use and disclose your health information to approved clinical research studies.  While most clinical research studies require specific patient consent, there are some instances where a retrospective record review with no patient contact may be conducted by such researchers.  For example, the research project may involve comparing the health and recovery of patients who received one medication for their medical condition to those who received a different medication for that same condition.

Regulatory Agencies:  DAA may disclose your health information to a health oversight agency for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations and inspections of the DAA.  These activities are necessary for the government and certain private health oversight agencies, e.g., the Department of Public Health and Environment to monitor compliance with the requirements of government programs or the Board of Medical Examiners to investigate consumer complaints regarding providers.

Law Enforcement/Litigation:  DAA may disclose your health information for law enforcement purposes as required by law or in response to a court order.

Public Health:  As required by law, DAA may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.  For example, DAA is required to report the existence of a communicable disease, such as acquired immune deficiency syndrome ("AIDS"), to the Department of Public Health and Environment to protect the health and well-being of the general public.

Workers’ Compensation:  DAA may release health information about you for workers' compensation or similar programs.  These programs provide benefits for work-related injuries or illnesses.

Military/Veterans:  DAA may disclose your health information as required by military command authorities, if you are a member of the armed forces.

As Otherwise Required by Law: DAA will disclose your health information in any situation in which such disclosure is required by law (e.g., child abuse, domestic abuse).

Your rights related to your health information:  Although all records concerning your treatment obtained at the DAA are the property of the DAA, you have the following rights concerning your medical information:

Right to Confidential Communications:  You have the right to receive confidential communications of your health information by alternative means or at alternative locations.  For example, you may request that DAA only contact you at work or by mail.

Right to Inspect and Copy:  You generally have the right to inspect and copy your health information, except as restricted by your physician or by law.

Right to Amend:  You have the right to request an amendment or correction to your health information.  If we agree that an amendment or correction is appropriate, we will ensure that the amendment or correction is attached to your medical record. 

Right to an Accounting:  You have the right to obtain a statement of the disclosures that have been made of your health information for any purpose other than for treatment, payment or routine operational purposes.

Right to Request Restrictions:  You have the right to request restrictions on certain uses and disclosures of your health information.  If we are able to agree to your request, we will abide by the restrictions.

Right to Receive Copy of this Notice:  You have the right to receive a paper copy of this Notice, upon request, if this Notice has been provided to you electronically.

Right to Revoke Consent or Authorization:  You have the right to revoke your consent or authorization to use or disclose your health information, except to the extent that action has already been taken in reliance on your consent or authorization.

For More Information Regarding How to Exercise These Rights: If you have questions or would like more information regarding any of the rights listed above, please contact:  The Denver Allergy & Asthma Associates, P.C.   HIPPA compliance officer @ 303-234-1067. 

If You Believe That Your rights Have Been Violated:  You may file a complaint with DAA or with the Secretary of the Department of Health and Human Services.  To file a complaint with DAA, please contact: HIPPA compliance officer at (303) 234-1067.  All complaints must be submitted in writing to Denver Allergy & Asthma Assoc, HIPPA compliance officer at 14142 Denver West Parkway, Suite 345 Golden, CO 80401.  There will be no retaliation for filing a complaint.

changes to this notice:  DAA will abide by the terms of the Notice currently in effect.  DAA reserves the right to change the terms of this Notice at any time.  Any new notice provisions will be effective for all protected health information that it maintains.  DAA will mail any revised Notice to the address indicated on the registration Forms or another address you may provide to us if requested in writing or it may be reviewed by going to the DAA web site at WWW.DAADOCS.COM.

notice effective date:  The effective date of the Notice is 10/16/02.

DENVER ALLERGY AND ASTHMA ASSOCIATES, P.C.

CONSENT TO USE AND DISCLOSE HEALTH INFORMATION

By signing this form, you are granting consent to Denver Allergy and Asthma Associates to use and disclose your protected health information for the purposes of treatment, payment, and health care operations. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review our Notice of Privacy Practices before you sign this consent, and we encourage you read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by: accessing our web site at WWW.daadocs.com or by contacting our main office at 303-234-1067 and requesting a copy be sent to you. You have a right to request that we restrict how we use and disclose your protected health information for the purposes of treatment, payment or health care operations. We are not required by law to grant your request. However, if we do  decide to grant your request, we are bound by our agreement.

You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your consent.

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Print Patient Name

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Patient/Responsible Party Signature                                                         Date

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize Denver Allergy and Asthma Associates the use or disclosure of my individually identifiable health information (PHI) as described below. I understand that this authorization is voluntary. I understand that, if the organization authorized to receive my PHI is not a health plan or health care provider, the released PHI may no longer be protected by federal privacy regulations.

Patient name:____________________________    ID Number:______________________

Persons/organizations authorized to receive your PHI:

_______I am requesting my PHI for my own use.

_______I am requesting that my PHI be sent to my primary care physician:

              _________________________________________________

              _________________________________________________

              _________________________________________________

Specific description of PHI to be released: All test results and medical records pertaining to any testing and treatment performed by Denver Allergy and Asthma Associates, P.C.

Specific restrictions you want placed on release of your PHI:____________________________________

_________________________________________________________________________________

I understand that this authorization will expire on: __/__/__ (DD/MM/YR) Initials:________

I understand that I may revoke this authorization at any time by notifying the releasing organization in writing, but my revocation will not affect any releases made or other actions taken before the date of my revocation.

                                                                                                               Initials:________

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Print Patient Name

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Patient/Responsible Party Signature                                                   Date