DallasAllergyImmunology

Stacy K. Silvers, M.D. Angela Hague, P.A.-C Robert W. Sugerman, M.D. Joanna G. Rolen, P.A.-C Richard L. Wasserman, M.D., Ph.D.

PLEASE DO NOT MAIL

BRING THIS INFORMATION TO YOUR FIRST APPOINTMENT

THE FIRST APPOINTMENT The initial visit involves a comprehensive evaluation focused on your major concerns about you or your child’s illness. This will take about 30-60 minutes. Often, laboratory tests are needed in order to come to an accurate and useful diagnosis that will guide treatment. Occasionally lung function tests, x-ray studies, immunizations, or allergy tests may be needed as well. You may meet with a nurse educator. The entire visit may take as long as three or four hours. You will receive a telephone call from our automatic calling system forty-eight (48) hours prior to your appointment. It is very important that we receive confirmation. Every effort will be made to explain the tentative diagnosis and initial plan during the first visit. Most of the time, the information available at the follow up visit is necessary to make the diagnosis and establish the treatment program. Please ask questions about anything that is not clear. Many people find it helpful to bring a written list of questions. The typical charge for initial evaluation is usually $300, but ranges from $175 to $450 depending on the complexity of the problem. Charges for allergy tests, lung function tests, or immunizations related to immunodeficiency evaluation are additional. Laboratory tests and x-rays are billed by the laboratory or hospital and will vary greatly depending on the individual needs of the patient. At this time, we are members of several HMO’s and PPO’s; please check with your insurance carrier to verify that we are participating providers. If we are not a provider and you receive a referral to see us from your primary care provider that does not guarantee that we will receive full payment. If you have a question about coverage, call our billing office at 972-566-7669.

4500 Hillcrest Road, Suite 150, Frisco, Texas 75035 Telephone (972) 566-7788 | Telefacsimile (972) 566-8837

www.dallasallergy.net

As a courtesy, we will file your insurance claim. You will be responsible for the co-pay required by your insurance plan at the time of the visit. If you have not met your insurance deductible, you will be asked for full payment at the time of the visit. You are also responsible for payment of all non-covered charges, at the time of the visit. If there are questions about the fees, please call our billing office at (972) 566-7669. We understand that illness is always a difficult experience and we will do everything that we can to help. We are looking forward to meeting you. Also, if you use an inhaler, please refrain from using this on the day of your appointment. Sincerely,

Stacy K. Silvers, M.D.

Robert W. Sugerman, M.D. Richard L. Wasserman, M.D., Ph.D.

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PATIENT INFORMATION

APPOINTMENTS AND EMERGENCIES: All new patients must confirm their appointment by 12:00 noon the day prior to their scheduled appointment. If your appointment is on a Monday, we request that you contact our office by 12:00 noon on Friday. If we do not receive a telephone call confirming your appointment, it will be cancelled. Appointments are scheduled by calling (972) 566-7788. If the scheduled appointment cannot be kept, please let us know at least 24 hours in advance so that another patient waiting for an appointment can be seen sooner. If you fail to keep your appointment or cancel in less than 24 hours, you will be billed a $25.00 fee. Repeated missed appointments may result in discharge from the practice. Please arrive at the office at least fifteen minutes prior to your appointment so that you can complete or provide additional information needed for your visit. If there is a problem between appointments, please call and we will decide together if the problem can be handled by telephone or if you or your child needs to be seen immediately or in the next 24 hours for a sick visit. You or your child may be seen by one of our highly trained physician assistants if the physician’s schedule is full. A physician is always available to consult with the physician assistant for specific problems. If you are seen by a physician assistant, your DallasAllergyImmunology physician will review the record of that visit. In the event of a medical emergency, call 911 and then notify our office if time permits. Our physicians have hospital privileges at Medical City Dallas and Children’s Medical Center. Life threatening emergencies should be directed to the nearest hospital emergency department. Ask the emergency room physician to call our on-call physician with an update after the patient is seen. TELEPHONE CALLS: The office telephone, (972) 566-7788, is answered 24 hours a day. If you feel that you or your child needs to be seen in the office on the day of the call, let the receptionist know and, if possible, she will work you into the schedule. If the problem is less urgent, you may leave a message on the nurse voice mail. Non-emergency sick calls received before 1:00 pm will be returned the same day. Telephone calls received after 1:00 pm may be returned by the next business day. The direct telephone number to the nurse line is 972-566-6144. Other requests will be returned within 24 hours. If you need help sooner, let us know. Some patients become upset when they call the office and cannot get through to the doctor. We have trained our staff and instructed them to handle all in-coming telephone calls. This procedure allows us to attend to patients with a minimum of interruptions. Please be patient, as this is a courtesy that you would want observed if you were the patient in the office at the time. Your call will be handled as soon as possible, if not immediately. We are very careful about returning phone calls during regular office hours and after hours. If you don’t get a telephone call back, there has been an error. Please call again. We may charge for telephone consultation that take place instead of an office visit. Calls for physician management of a new problem, including counseling, medical management and coordination of care not resulting in an office visit are charged. You will be responsible for any charges that are not covered by your insurance company.

SECURE MESSAGING: Once you have become a patient at our office you will be able to register for secure messaging through our website. We encourage our patients to use secure messaging to communicate non-urgent medical questions; request appointments or prescription refills; or contact our billing department. Our staff will be happy to assist you in setting up secure messaging. PRESCRIPTIONS AND REFILLS: All medications, including refills are prescribed based on you or your child’s current condition. Follow up appointments are scheduled so that we can monitor you or your child’s condition and adjust the medicines accordingly. If the last appointment was not kept, refills for a limited period may be given to allow time for a new appointment. Calls for prescription refills should be made between 9:00 am and 4:00 pm. Your medical record, which is only available in the office, is needed to determine whether a refill should be issued. Therefore, you must keep track of medication needs and call for refills during office hours. Refill requests will be handled more efficiently if your pharmacist calls our Pharmacy Line (972) 566-8107 and leaves a message. Requests left before noon will be called in the same day, requests after 1:00 pm will be called in by noon the following day. Remember that refills may be requested through our secure messaging system. Replacement prescriptions for prescriptions that were lost or expired before being filled by the pharmacy will be reissued at a charge of $15.00 per prescription. LABORATORY RESULTS: Laboratory test results return at different times and may take as long as two weeks. These results are reviewed as they come in. If there is an abnormal result that requires prompt action, we will contact you immediately. Otherwise, simple results may be communicated by a telephone call or our secure messaging system and the results will be discussed in full at your next visit. REQUESTS FOR SPECIAL LETTERS, FORMS, & MEDICAL RECORDS: Requests for special letters and forms (e.g., for school, camp, travel or work) should be made through the nurse line or our secure messaging system through our website. Forms may be mailed or faxed. Please include the patient’s name, date of birth, and specify the name and address or fax number to which the letter or form is to be sent. When completion of the form requires that the patient's paper medical record be retrieved and reviewed with needed information copied or summarized, a fee of not less than $5.00 will be charged. Allow 10 business days for letters and forms to be completed and either faxed or mailed. Written requests for medical records should be directed to our office either by mail, fax, or secure email. Please include the patient’s name, date of birth, and specify the name and address or fax number to which the records are to be sent. Paper copies will incur a charge of $25.00 for the first twenty pages and fifty cents per page, thereafter, plus postage. Please allow 15 business days for transfer of medical records.

BILLING: Full payment is due on the day of service. If the patient is a minor, the patient’s accompanying adult, parent, or legal guardian is responsible for payment at the time of services. This includes all insurance copays. We accept cash, checks, Visa, MasterCard, Discover, American Express and debit cards. You can make arrangements for your health care bills to be automatically charged to your credit card. We will charge the credit card each month for the previous month’s activity. An administrative staff member can provide more detailed information. Because our services are personal and directed to you or your child we ask that communications with your insurance company become your responsibility. Our office staff will be happy to answer any questions about the bill and to assist you with your insurance in any way that we can. Call our billing office at (972) 566-7669 for questions or problems. If you are a member of a pre-paid health plan (HMO, PPO or other insurance) that requires preapproval for the visit, it is your responsibility to obtain the referral or authorization. Your plan may also require that tests be performed by a designated facility. It is your responsibility to tell us of this requirement. If the required referral is not obtained, you may be fully liable for the charges associated with the visit. PAST DUE ACCOUNTS: An account is considered past due 30 days following billing. There is a $25.00 late fee applied to your account if we do not receive full payment by the expected due date stated on your statement. Unpaid accounts beyond 90 days are considered delinquent and may be forwarded to a collection agency and/or attorney. All accounts must be current at the time of an office visit. MISSED APPOINTMENTS & SPECIAL PROCDURES: We appreciate the courtesy of a call if you are unable to keep an appointment. Please notify our office at least twenty-four (24) hours prior to the appointment time. We will charge a $25.00 fee for each appointment that is not cancelled at least twenty-four (24) hours before the scheduled time. Your doctor may order a special procedure such as RUSH Immunotherapy or a food Challenge. These special procedures are performed in our office and require additional medical staff to assist with the procedure. The procedure may also include special supplies or drugs that need to be purchased in advance by our office. RUSH Immunotherapy and food challenges require significant preparation prior to the actual procedure. Therefore, if you are unable to come to the office on the scheduled date, please notify our office immediately. If you cancel a special procedure less than 48 hours in advance you will be charged $100.00. This fee is not refundable and will not be billed to your insurance company.

Patient Information (please print) Date: ____/____/________ Patient Name:_____________________________________________ Sex: _____________ Date of Birth: ____/____/________ Social Security #: _______-____-________ African American ____American Indian ____Caucasian/Non-Hispanic ____ Hispanic _____ Oriental/Asian _____ Other ____ Address: __________________________________________________________ City: _________________________ State: __________ Zip Code: ___________ Home Phone: (_____)______-________ Guarantor Information Guarantor Name:____________________________________________________ Address: __________________________________________________________ City: _________________________ State: ____________Zip Code: __________ Home Phone: (_____)______-________ Mobile Phone: (_____)______-_______ Employer: _________________________________________________________

Address: _____________________________________________________ Work Phone: (_____)______-________

Other Contacts Name: __________________________________Relationship:________________ Home Phone (_____) _____-_________ Mobile Phone: (______) ______-_______ Referred by: _______________________________________________________ Referring Physician: _____________________ Phone: (_____)______-________ Primary Care Physician ___________________ Phone:(_____)______-________ 1st Insurance Coverage: ______________________________________________ Address: __________________________________________________________ City: ________________________ State: ____________Zip Code: ___________ Phone: (_____)______-________ Subscriber Name: ___________________________________________________ Sex: ______ Date of Birth: ____/____/________ Social Security #: ______/_____/____ ID #: _________________________ Group Number #: ______________________________ 2ND Coverage: ______________________________________________________ Address: __________________________________________________________ City: ________________________ State: ____________Zip Code: ___________ Phone: (_____)______-________ Subscriber Name: ___________________________________________________ Sex: ______Date of Birth: ____/____/______ Social Security#: ______/_____/____ ID #: _________________________ Group Number #: ______________________________

DallasAllergyImmunology

ALLERGY SKIN TESTING INSTRUCTIONS Allergy skin testing provides a fast, safe and reliable means for identifying allergic sensitivities to inhalant allergens (e.g., pollens, molds, dust mites and animal danders) and is also used sometimes to diagnose allergic sensitivities to insect stings, antibiotics and foods. The information obtained from allergy testing provides guidance for avoidance of allergens, the most important and first step in the treatment of any allergic disorder. Test results may also be used to formulate allergy shot extracts. In order to make your allergy testing appointment as productive as possible, we ask that you review the following instructions prior to your appointment: 1. Although the testing itself may be completed in one hour or less, additional time may be needed to discuss results, allergy avoidance measures and treatment options. 2. Wear a shirt or blouse, which can be removed easily. Prick skin testing is performed using the Multitest™ device applied to the back. 3. The medications listed below will interfere with allergy skin testing and should be discontinued in the time specified. If you have a medical condition or severe allergic symptoms which might worsen without medications, please consult us prior to stopping these medications. If you have forgotten to stop these medications by the specified time, please consult one of our nurses to determine whether or not you need to reschedule your allergy testing appointment. ALL OTHER MEDICATIONS NOT LISTED BELOW WILL NOT INTERFERE WITH SKIN TESTING AND SHOULD BE CONTINUED AS PRESCRIBED !!! DISCONTINUE 10 DAYS PRIOR TO SKIN TESTING: Cetirizine (Zyrtec) Cyproheptadine (Periactin) Imipramine (Tofranil) ** Levocetirizine (Xyzal) Doxepin (Sinequan, Adapin) Chlorpromazine

(Thorazine) ** Desloratadine (Clarinex) Amitriptyline (Elavil) ** Thioridazine (Mellaril) ** Loratadine (Claritin, Alavert)

Nortriptyline (Pamelor, Aventyl) **

Thiothixene (Navane) **

Fexofenadine (Allegra) Clomipramine (Anafranil) ** Trifluoperazine (Stelazine) **

Hydroxyzine (Atarax, Vistaril)

Desipramine (Norpramin) **

** IF YOU ARE TAKING A STARRED MEDICATION, YOU MUST FIRST CONSULT WITH THE PRESCRIBING PHYSICIAN TO DETERMINE IF IT IS SAFE TO DISCONTINUE.

DISCONTINUE 5 DAYS PRIOR TO SKIN TESTING: Chlorpheniramine (many prescription & OTC brands, including Ahchew, Chlor-Trimeton, DAllergy, Deconamine, Durahist, Extendryl, Histavent, Omnihist, Rescon, Rynatan, Triaminic Cold & Allergy, Triaminic Multi-Symptom) Diphenhydramine (many OTC brands, including Benadryl, Tylenol PM, Tylenol Cold & Sinus, Triaminic Night Time Cold & Cough, Advil Cold & Sinus, Sominex, Nytol) Brompheniramine (Dimetapp, Bromfed) Tripelennamine (Actifed, PBZ) Certain Medications for Motion Sickness / Nausea: Dramamine, Compazine, Meclizine (Antivert), Phenergan (promethazine) Anihistamine Nasal Sprays: Astelin, Astepro, Patanase, Dymista. NOTE: all other nasal sprays are OK! Antihistamine Eye Drops: Alomide, Livostin, Optivar, Pataday, Patanol DO NOT DISCONTINUE THE FOLLOWING MEDICATIONS: Medications for Asthma: including Advair, Flovent, Pulmicort, Qvar, Asmanex, Singulair and Zyflo Topical cortisone nasal sprays: including Flonase, Nasonex, Nasacort, Rhinocort, Veramyst Medications for acid reflux, high blood pressure and other chronic medical conditions. PLEASE CALL OUR OFFICE AND ASK TO SPEAK WITH A NURSE IF YOU HAVE ANY ADDITIONAL QUESTIONS REGARDING THESE INSTRUCTIONS.

ALLERGY & ASTHMA ASSOCIATES OF NORTH TEXAS 4500 HILLCREST, SUITE 150 FRISCO, TEXAS 75035 N W - E S

N W - E S

New Patient History

Legal Name: __________________ DOB: _______ Today’s date: _______

Referred by: _________________ Primary Care Physician: ______________ Chief Complaint (major problem that you would like to solve): _________________ ____________________________________________________ Summary of the major problem: __________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Medication: Please use back of sheet to add additional medications or comments. Asthma Drugs (inhaled and oral) Dose Daily As Needed Allergy Drugs (sprays and oral) Dose Daily As Needed Eczema Drugs (topicals and oral) Dose Daily As Needed Other Drugs (including over the counter) Dose Daily As Needed Epipen Jr. Please circle one YES NO Epipen Please circle one YES NO Any Known Drug Allergies _____________________________________________________________________ What happens when this drug is taken? Ra s h Hive s Othe r __________________________________ Please use this section to provide any detailed information not included within the questionnaire. Additional Asthma history details: _______________________________________________________________ Additional Allergy history details: _______________________________________________________________ Previous Allergy Testing: Doctor’s Name: ________________________ City: ___________________________ Allergy shot reaction details: ____________________________________________________________________ Eczema history details: ________________________________________________________________________ Hives history details: __________________________________________________________________________ Food history details: __________________________________________________________________________ Stinging insect reaction details: _________________________________________________________________ Infection history: ____________________________________________________________________________ Pregnancy/Labor/Delivery problems: __________________________________ Birth weight: ______________ Major Problems/Hospitalizations/Surgeries: _______________________________________________________ Social history details: _________________________________________________________________________ Mother’s age: _________ Father’s age: __________ Number of brothers and sisters: __________________ Family History, Additional: ____________________________________________________________________ ________________________________________________________________________________________

DallasAllergyImmunology

THE CONSENTS BELOW ARE REQUIRED BY FEDERAL REGULATIONS ___________________________________________________________ Patient Name

With my consent, the physicians may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to this practice’s Notice of Privacy Practices for a more complete description of such uses and disclosures. (This permits us to treat you and share information with your other physicians and insurance companies.) __________ _________ (Please initial) Yes No I have the right to review the Notice of Privacy Practices prior to signing this consent. The physicians reserve the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy practices may be obtained by forwarding a written request to: DallasAllergyImmunology (DAI), Privacy Officer at 7777 Forest Lane, Suite B332, Dallas, TX 75230. (This says that you know you can ask to see and receive the details.) __________ _________ (Please initial) Yes No With my consent, the physician’s office may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and may call pertaining to my clinical care, including laboratory results among others. (This permits us to call you and leave a message.) __________ _________ (Please initial) Yes No With my consent, this practice may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. (This permits us to send you letters) __________ _________ (Please initial) Yes No

With my consent, this practice may send secure messages to my home e-mail or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. (This permits us to send secure messages to your email.) __________ _________ (Please initial) Yes No With my consent, this practice may fax to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. (This permits us to send you a fax.) __________ _________ (Please initial) Yes No DAI has an active clinical research program. Many of our patients choose to participate. We will not contact you about research studies without your permission. May we contact you about opportunities we think may interest you? __________ _________ (Please initial) Yes No May we leave information with a spouse, significant other, parent? __________ _________ (Please initial) _____________________________________ Yes No Persons Name For any patient above the age of 18, still living at home or at college, may we discuss your appointments/treatment/insurance matters with your parent(s) or guardian? __________ _________ (Please initial) Yes No By signing this form, I am consenting to the practice’s use and disclosure of my Protected Health Information to carry out Treatment Payment and Health Care Operation. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, this practice may decline to provide treatment to me. I have read and understand the guidelines of this practice. _________________________________ ______________________ Signature of Patient or Responsible Party Date

DallasAllergyImmunology

Debit/Credit Card Authorization Dear Patient, Our office is implementing a new payment policy to help lower the costs associated with our services. Our staff works hard to verify your insurance benefits prior to your visits, making the amount we collect from you at the time of your visit as accurate as possible. We quote the information that we receive from your insurance company. Your insurance company will be billed for applicable charges for today’s services. After an explanation of benefits (EOB) and payment has been received from your insurance company, we will charge your credit card for any remaining balance due. Additionally, if your insurance company has not paid the claim with 90 days, we will charge your debit/credit card for the balance due. Should your insurance company subsequently make payment to our office we will refund your debit/credit card immediately. This policy in no way compromises your ability to dispute a charge or questions your insurance company’s determination of payment. It is our hope that this new policy will work to our mutual advantage since you will no longer have to send a check or give debit/credit card information over the telephone. This will greatly decrease the number of statements generated and mailed each month. Please note that your information will be stored in our secure accounting system. As always, we strive to provide you with the highest level of care and look forward to continuing to do so. Patient Name ________________________________________ Signature __________________________________ Date ___________ Printed name ________________________________ Debit/Credit card # _____________________________ Expiration Date _______ Security code ___________________ Please contact me at _______________________ if payment exceeds________ Please check one: □ Leave Message of balance to charge or □ Need verbal ok before running card By signing this form, I authorize DallasAllergyImmunology to charge my debit/credit card for the balance due on my account.

7777 Forest Lane, Suite B-332, Dallas, Texas 75230 ● 4500 Hillcrest Road, Suite 150, Frisco, Texas 75035 Telephone (972) 566-7788 ● Telefacsimile (972) 566-8837

www.dallasallergy.net

NOTICE CONCERNING COMPLAINTS

Complaints about physicians, as well as other licensees and registrants of the Texas State Board of Medical Examiners, including physician assistants and acupuncturists may be reported for investigation at the following address: Se pueden presentar quejas acerea de medicos asi tambien como otras personas autorizadas y registradas por la Junia de Examinadores Medicos de Texas (Texas State Board of Medical Examiners). Incluyendo a ayaudantes medicos y acupuntristas, papa su investigacion, en la siguiente direccion:

Texas State Board of Medical Examiners Attention Investigations

1812 Centre Creek Drive, Suite 300 P. O. Box 149134

Austin, TX 78714-9134

NOTICE OF PRIVACY PRACTICES

DallasAllergyImmunology 7777 Forest Lane Suite B332 Dallas, TX 75230 and Allergy and Asthma of North Texas 4500 Hillcrest Road Suite 150 Frisco, TX 75035

Janet McGovern Office Administrator 972-566-7788

Effective Date: September 23, 2013

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.

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer listed above.

TABLE OF CONTENTS

A. How This Medical Practice May Use or Disclose Your Health Information

B. When This Medical Practice May Not Use or Disclose Your Health Information

C. Your Health Information Rights

1. Right to Request Special Privacy Protections

2. Right to Request Confidential Communications

3. Right to Inspect and Copy

4. Right to Amend or Supplement

5. Right to an Accounting of Disclosures

6. Right to a Paper or Electronic Copy of this Notice

D. Changes to this Notice of Privacy Practices

E. Complaints

A. How This Medical Practice May Use or Disclose Your Health Information

This medical practice collects health information about you and stores it in a chart on a computer in an electronic health record/personal health record. This is your medical record. The medical record is the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:

1. Treatment. We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians or other health care providers who will provide services that we do not provide. Or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test. We may also disclose medical information to members of your family or others who can help you when you are

sick or injured, or after you die.

2. Payment

3.

. We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health plan the information it requires before it will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.

Health Care Operations

4.

. We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. Or we may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. We may also share your medical information with our "business associates," such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts. We may also share medical information about you with the other health care providers, health care clearinghouses and health plans that participate with us in "organized health care arrangements" (OHCAs) for any of the OHCAs' health care operations. OHCAs include hospitals, physician organizations, health plans, and other entities which collectively provide health care services. A listing of the OHCAs we participate in is available from the Privacy Official.

Appointment Reminders

5.

. We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.

Sign In Sheet

6.

. We may use and disclose medical information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.

Notification and Communication With Family

7.

. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

Sale of Health Information.

8.

We will not sell your health information without your prior written authorization. The authorization will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization.

Required by Law

9.

. As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.

Public Health. We may, and are sometimes required by law, to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.

10. Health Oversight Activities

11.

. We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by law.

Judicial and Administrative Proceedings

12.

. We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.

Law Enforcement

13.

. We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.

Coroners

14.

. We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths.

Organ or Tissue Donation

15.

. We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

Public Safety

16.

. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

Proof of Immunization

17.

. We will disclose proof of immunization to a school that is required to have it before admitting a student where you have agreed to the disclosure on behalf of yourself or your dependent.

Specialized Government Functions

18.

. We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.

Workers’ Compensation

19.

. We may disclose your health information as necessary to comply with workers’ compensation laws. For example, to the extent your care is covered by workers' compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers' compensation insurer.

Change of Ownership

20.

. In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.

Breach Notification

21.

. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate. [Note: Only use e-mail notification if you are certain it will not contain PHI and it will not disclose inappropriate information. For example if your e-mail address is "digestivediseaseassociates.com" an e-mail sent with this address could, if intercepted, identify the patient and their condition.]

Research

B. When This Medical Practice May Not Use or Disclose Your Health Information

. We may disclose your health information to researchers conducting research with respect to which your written authorization is not required as approved by an Institutional Review Board or privacy board, in compliance with governing law.

Except as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

C. Your Health Information Rights

1. Right to Request Special Privacy Protections

2.

. You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.

Right to Request Confidential Communications

3.

. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

Right to Inspect and Copy

4.

. You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary. We may deny your request under limited circumstances. If we deny your request to access your child's records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.

Right to Amend or Supplement

5.

. You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.

Right to an Accounting of Disclosures

6.

. You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 18 (specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.

Right to a Paper or Electronic Copy of this Notice

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.

. You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail.

D. Changes to this Notice of Privacy Practices

We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of

Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment. We will also post the current notice on our website.

E. Complaints

Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Jorge Lozano, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 1301 Young Street, Suite 1169 Dallas, TX 75202 Voice Phone (800) 368-1019 FAX (214) 767-0432 TDD (800) 537-7697

The complaint form may be found at www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf

You will not be penalized in any way for filing a complaint.

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