DAVIS EAR, NOSE AND THROAT SPECIALISTS

407 S Medical Arts Ct Ste C ·

Gillette, Wyoming 82716

Notice of Privacy Practices

1 We are committed to the privacy of our patients. We collect your medical information for purposes of diagnosing and treating your medical problems. This notice describes how your medical information may be used and disclosed and how you can access this information. Please review this Notice carefully.

OUR PLEDGE REGARDING MEDICAL INFORMATION

This Notice describes the privacy practices of Davis ENT Specialists, P.C. and any health care professional authorized to enter information into your medical record. We create a record of the care and services you receive in order to provide you with quality care and to comply with certain legal requirements. This record of care includes certain “protected health information” about you, including your name, address, telephone number, and similar personal information which may relate to your past, present, or future physical or mental health condition and related health care services. 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. As the laws change, this Notice will be updated and apply to all protected health information which we maintain. If you would like to receive an updated copy of this Notice, please let us know.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we 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. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to our office at the address found on the last page of this notice. 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.

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 our office. To request an amendment, your request must be made in writing and submitted to our office. 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 may 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 us; 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 medical information about you for purposes other than treatment, payment, and health care operations. To request this list or accounting of disclosures, submit your request in writing to our office.

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 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 of your care. 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 emergency treatment. To request restrictions, you must make your request in writing to our office at the address on the last page of this notice. In your request, you must tell us (1) what information you want us to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.

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, you must make your request in writing to our office. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice at any time. Even if you agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

Changes to This Notice: We reserve the right to change this notice. We 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 DAVIS EAR, NOSE AND THROAT SPECIALISTS 407 S Medical Arts Ct Ste C · Gillette, Wyoming 82716 Effective 04/11/2011 Ph: (307) 686.7346 · Fx: (307) 682.1485 · www.davisent.net in the future. We will post a copy of the current notice in the waiting room at our office.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, please submit it to the address below, in writing.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

We may use and disclose your medical information for the following purposes:

For Treatment: We may use medical information about you to provide you with medical treatment or services, to tell you about or recommend possible treatment options or alternatives which may be of interest to you. The information will be provided to doctors, nurses, technicians, or other personnel who are involved in taking care of you and people outside of our office who provide services that are related to your care.

For Payment: We may use and disclose medical information about you so that the treatment and services you receive may be billed to, and payment may be collected from you, an insurance company, or another third party. We may also disclose medical information to obtain prior approval or to determine whether your plan will cover your treatment.

For Health Care Operations and Appointment Reminders: We may use and disclose medical information about you for health care operations and to contact you and remind you of an appointment. This would include reviewing treatment and services provided to you and to evaluate our staff in caring for you.

Individuals Involved in Your Care or Payment for your Care: We may release information about you to a family member or friend who is involved in your care, or the payment for your care. We may tell your family or friends your condition.

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 an immediate, 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 the threat.

To Coroners, Funeral Directors, and Organ and Tissue Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the director to carry out his or her duties. If you are an organ donor, we may release medical information to organizations that handle organ or tissue procurement or to an organ donation bank, for organ or 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 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: to prevent or control disease, injury or disability; to report births and deaths; 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 contacting 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.

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: We may disclose medical information about you in response to a subpoena, discovery request, or other lawful order from a court. Law Enforcement: We may release medical information if asked to do so by a law enforcement official as a part of law enforcement activities; in investigation of criminal conduct or of victims of crime; in response to court orders; in emergency circumstances; or when required by law.