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Legacy Male Health Institute,
P.A.
Notice of Privacy Practices
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.
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Each time you have contact with a healthcare provider,
a record of your visit is prepared. This record contains
demographics, presenting signs/symptoms, results of
the examination and tests, diagnoses, treatment and
future care. Your medical record is the physical property
of the medical practice, but you have certain rights
to restrict some of the uses or disclosures of the information
in your medical record. Male Fertility Specialists,
P.A., however, has the right to use and disclose the
information contained in your medical record for the
following:
Uses and Disclosures
Treatment. Your health information
may be used by staff members or disclosed to other health
care professionals for the purpose of evaluating your
health, diagnosing medical conditions, and providing treatment.
For example, results of laboratory tests and procedures
will be available in your medical record to all health
professionals who may provide treatment or who may be
consulted by staff members.
Payment. Your health information may be used to
obtain reimbursement for services, confirming coverage,
billing or collection activiites, and utilization review.
Health care operations. Your health information
may be used as necessary to support the day-to-day activities
and management of Male Fertility Specialists, P.A.. For
example, information on the services you received may
be used to support budgeting and financial reporting,
and activities to evaluate and promote quality.
Law enforcement. Your health information may be
disclosed to law enforcement agencies to support government
audits and inspections, to facilitate law-enforcement
investigations, and to comply with government mandated
reporting.
Public health reporting. Your health information
may be disclosed to public health agencies as required
by law. For example, we are required to report certain
communicable diseases to the state's public health department.
Other uses and disclosures require your authorization.
Disclosure of your health information or its use for any
purpose other than those listed above requires your specific
written authorization. If you change your mind after authorizing
a use or disclosure of your information you may submit
a written revocation of the authorization. However, your
decision to revoke the authorization will not affect or
undo any use or disclosure of information that occurred
before you notified us of your decision to revoke your
authorization.
Additional Uses of Information
Appointment reminders. Your health
information will be used by our staff to send you appointment
reminders.
Information about treatments. Your health information
may be used to send you information that you may find
interesting on the treatment and management of your medical
condition..
Individual Rights
You have certain rights under the federal
privacy standards. These include:
the right to request restrictions on the use and disclosure
of your protected health information
• the right to receive confidential communications
concerning your medical condition and treatment
• the right to inspect and copy your protected health
information
• the right to amend or submit corrections to your
protected health information
• the right to receive an accounting of how and to
whom your protected health information has been disclosed
• the right to receive a printed copy of this notice
Male Fertility Specialists, P.A. Duties
Protecting your privacy and maintaining the security of
your health information is one of the most important responsibilities
of Male Fertility Specialist, P.A.
We are required by law to maintain the privacy of your
protected health information and to provide you with this
notice of privacy practices. We also are required to abide
by the privacy policies and practices that are outlined
in this notice.
Right to Revise Privacy Practices
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 and state laws and regulations.
Upon request, we will provide you with the most recently
revised notice on any office visit. The revised policies
and practices will be applied to all protected health
information we maintain.
Requests to Inspect Protected Health Information
You may generally inspect or copy the protected
health information that we maintain. As permitted by federal
regulation, we require that requests to inspect or copy
protected health information be submitted in writing.
You may obtain a form to request access to your records
by contacting our receptionist or Privacy Officer. Your
request will be reviewed and will generally be approved
unless there are legal or medical reasons to deny the
request.
Complaints
If you would like to submit a comment or
complaint about our privacy practices, you can do so by
sending a letter outlining your concerns to:
Attetionn: Privacy Officer
Legacy Male Health Institute,
P.A.
5616 Warren Parkway
Friscoe, Texas 75034
If you believe that your privacy rights
have been violated, you should call the matter to our
attention by sending a letter describing the cause of
your concern to the same address.
You will not be penalized or otherwise retaliated against
for filing a complaint.
Contact Person
The name and address of the person you can
contact for further information concerning our privacy
practices is:
Attetionn: Privacy Officer
Legacy Male Health Institute, P.A.
5616 Warren Parkway
Friscoe, Texas 75034
972-612-7131 Ext. 202
Effective Date
This Notice is effective on or after April 14, 2003.
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