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.
Protected health information about you is obtained as a record of your contacts
or visits for healthcare services with Polina Kaloyanova, M.D., P.A. This
information is called protected health information. Specifically, "Protected
Health Information" is information about you, including demographic information
(i.e., name, address, phone, etc.) that may identify you and relates to your
past, present or future physical or mental health condition and related health
Polina Kaloyanova, M.D., P.A. is required to follow specific rules on maintaining
the confidentiality of your protected health information, how our staff uses
your information, and how we disclose or share this information with other
healthcare professionals involved in your care and treatment. This Notice
describes your rights to access and control your protected health information.
It also describes how we follow those rules and use and disclose your protected
health information to provide your treatment, obtain payment for services
you receive, manage our health care operations and for other purposes that
are permitted or required by law.
If you have any questions about this Notice please contact our Privacy Manager
at (469) 694-8777.
Your Rights Under The Privacy Rule
Following is a statement of your rights, under the Privacy Rule, in reference
to your protected health information. Please feel free to discuss any questions
with our staff.
You have the right to receive and we are required to provide you with a copy
of this Notice of Privacy Practices - We are required to follow the terms
of this notice. We reserve the right to change the terms of our notice, at
any time. If needed, new versions of this notice will be effective for all
protected health information that we maintain at that time. Upon your request,
we will provide you with a revised Notice of Privacy Practices if you call
our office and request that a revised copy be sent to you in the mail or ask
for one at the time of your next appointment.
You have the right to authorize other use and disclosure - This means you
have the right to authorize or deny any other use or disclosure of protected
health information not specified in this notice. You may revoke an authorization,
at any time, in writing, except to the extent that your physician or our office
has taken an action in reliance on the use or disclosure indicated in the
For Payment - Your protected health information will be used, as needed, to
obtain payment for our health care services. This may include certain activities
that your health insurance plan may undertake before it approves or pays for
the health care services we recommend for you such as making a determination
of eligibility or coverage for insurance benefits, reviewing services provided
to you for medical necessity, and undertaking utilization review activities.
For Healthcare Operations - We may use or disclose, as needed, your protected
health information in order to support the business activities of our practice.
This includes, but is not limited to, business planning and development, quality
assessment and improvement, medical review, legal services, and auditing functions.
It also includes education, provider credentialing, certification, underwriting,
rating, or other insurance related activities. Additionally, it includes business
administrative activities such as customer service, compliance with privacy
requirements, internal grievance procedures, due diligence in connection with
the sale or transfer of assets, and creating de-identified information.
Other Permitted and Required Uses and Disclosures
We may also use and disclose your protected health information in the following
instances. You have the opportunity to agree or object to the use or disclosure
of all or part of your protected health information.
To Others Involved in Your Healthcare - Unless you object, we may disclose
to a member of your family, a relative, a close friend or any other person
you identify, your protected health information that directly relates to that
person's involvement in your health care. If you are unable to agree or object
to such a disclosure, we may disclose such information as necessary if we
determine that it is in your best interest based on our professional judgment.
We may use or disclose protected health information to notify or assist in
notifying a family member, personal representative or any other person that
is responsible for your care of your general condition or death. If you are
not present or able to agree or object to the use or disclosure of the protected
health information, then your physician may, using professional judgment,
determine whether the disclosure is in your best interest. In this case, only
the protected health information that is relevant to your health care will
As Required by Law - We may use or disclose your protected health information
to the extent that the use or disclosure is required by law.
For Public Health - We may disclose your protected health information for
public health activities and purposes to a public health authority that is
permitted by law to collect or receive the information.
For Communicable Diseases - We may disclose your protected health information,
if authorized by law, to a person who may have been exposed to a communicable
disease or may otherwise be at risk of contracting or spreading the disease
For Health Oversight - We may disclose protected health information to a health
oversight agency for activities authorized by law, such as audits, investigations,
In Cases of Abuse or Neglect - We may disclose your protected health information
to a public health authority that is authorized by law to receive reports
of child abuse or neglect. In addition, we may disclose your protected health
information if we believe that you have been a victim of abuse, neglect or
domestic violence to the governmental entity or agency authorized to receive
such information. In this case, the disclosure will be made consistent with
the requirements of applicable federal and state laws.
To The Food and Drug Administration - We may disclose your protected health
information to a person or company required by the Food and Drug Administration
to report adverse events, product defects or problems, biologic product deviations,
track products; to enable product recalls; to make repairs or replacements,
or to conduct post marketing surveillance, as required.
For Legal Proceedings - We may disclose protected health information in the
course of any judicial or administrative proceedings, in response to an order
of a court or administrative tribunal (to the extent such disclosure is expressly
authorized), in certain conditions in response to a subpoena, discovery 0request
or other lawful process.
To Law Enforcement - We may also disclose protected health information, so
long as applicable legal requirements are met, for law enforcement purposes.
To Coroners, Funeral Directors, and Organ 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 funeral
director to carry out their duties. Protected health information may be used
and disclosed for cadaveric organ, eye or tissue donation purposes.
In Cases of Criminal Activity - Consistent with applicable federal and state
laws, we may disclose your protected health information if we believe that
the use or disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public. We may also disclose
protected health information if it is necessary for law enforcement authorities
to identify or apprehend an individual.
For Military Activity and National Security - When the appropriate conditions
apply, we may use or disclose protected health information of individuals
who are Armed Forces personnel (1) for activities deemed necessary by appropriate
military command authorities (2) for the purpose of a determination by the
Department of Veterans Affairs of your eligibility for benefits or (3) to
foreign military authority if you are a member of that foreign military services.
For Workers' Compensation - Your protected health information may be disclosed
by us as authorized to comply with workers' compensation laws and other similar
When an Inmate - We may use or disclose your protected health information
if you are an inmate of a correctional facility and your physician created
or received your protected health information in the course of providing care
Required Uses and Disclosures - Under the law, we must make disclosures about
you and when required by the Secretary of the Department of Health and Human
Services to investigate or determine our compliance with the requirements
of the Privacy Rule.
You have the right to designate a personal representative - This means you
may designate a person with the delegated authority to consent to, or authorize
the use and disclosure of protected health information.
You have tine right to inspect and copy your protected health information
- This means you may inspect and obtain a copy of protected health information
about you that is contained in your patient record. In certain cases we may
deny your request.
You have the right to request a restriction of your protected health information
- This means you may ask us, in writing, not to use or disclose any part of
your protected health information for the purposes of treatment, payment or
healthcare operations. You may also request that any part of your protected
health information not be disclosed to family members or friends who may be
involved in your care or for notification purposes as described in this Notice
of Privacy Practices. In certain cases we may deny your request for a restriction.
You may have the right to have us amend your protected health information
- This means you may request an amendment of your protected health information
for as long as we maintain this information. In certain cases, we may deny
your request for an amendment.
You have the right to request disclosure accountability - This means that
you may request a listing of your protected health information disclosures
we have made to entities or persons outside of our office.
You may complain to us or to the Secretary of Health and Human Services if
you believe your privacy rights have been violated by us. You may file a complaint
with us by notifying our Privacy Manager of your complaint.
How We May Use or Disclose Protected Health Information
Following are examples of use and disclosures of your protected health care
information that we are permitted to make. These examples are not meant to
be exhaustive, but to describe the types of uses and disclosures that may
be made by our office.
We may use and disclose your protected health information to provide, coordinate,
or manage your health care and any related services. This includes the coordination
or management of your health care with a third party that is involved in your
care and treatment. For example, we would disclose your protected health information,
as necessary, to a pharmacy that would fill your prescriptions. We will also
disclose protected health information to other physicians who may be involved
in your care and treatment.
We may also call you by name in the waiting room when your physician is ready
to see you. We may use or disclose your protected health information, as necessary,
to contact you to remind you of your appointment. We may contact you by phone
or other means to provide results from exams or tests and to provide information
that describes or recommends treatment alternatives regarding your care. And,
we may contact you to provide information about health related benefits and
services offered by our office.
Notice of Privacy Practices Polina Kaloyanova, M.D., P.A.