Patient Rights and Privacy Information

I understand that there are charges for services received at the WTAMU Speech and Hearing Clinic. Payment for my visit is expected at the time of service.

If I have health insurance, the WTAMU Speech and Hearing Clinic will file a claim to my health insurance company/carrier as applicable. I am responsible for all co-pays, deductibles, co-insurance, non-covered services, and balances remaining after insurance payment.

If I do not have health insurance, I will contact the WTAMU Speech and Hearing Clinic and make payment arrangements prior to receiving services. 

Notice of Privacy Practices - HIPAA      

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

In order to protect the privacy of your medical information, we adhere to the requirements of the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA) as follows:

• WT Students: FERPA applies to the records of patients who are students of West Texas A&M University (WT) (i.e., HIPAA does not apply). If you are a student of WT, please refer to our Notice Regarding Confidentiality of Health Records under FERPA for a description of the privacy practices that we will abide by with respect to your medical information. 

• All other patients: HIPAA applies to the records of patients who are not students of WT (i.e., FERPA does not apply). If you are not a student of WT, we are required to provide you with this Notice of Privacy Practices (this Notice) and will abide by this Notice with respect to your medical information. 

Our Uses and Disclosures

We may and we will routinely use and disclose your protected health information (PHI) only for each of the following purposes: treatment, payment, and health care operation.

• Treatment means providing, coordinating, or managing health care and related services by our healthcare providers. An example of this is a primary care doctor referring you to a specialist doctor and sharing information with the specialist to care for you. 

• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. Examples of this would include filing your health insurance claim for your visit, providing records to the insurance company in order to evaluate and process a claim, or verifying insurance coverage prior to a visit. 

• Health care operations include business aspects of running our practice, such as conducting quality assessments and improvement activities, auditing functions, cost management analysis, and customer service. Examples of this would be new patient survey cards or routine insurance claim audits and chart review. 

Our practice may also be required or permitted to disclose your PHI by law or for other legitimate reasons (e.g., to lessen a serious and imminent threat to health or safety). In all such situations, we will do our best to assure its continued confidentiality to the extent possible. 

In addition, we may use or share your information for health research. For all types of research that use or disclose identified health information from your records, we will obtain your written authorization except when (a) an Institutional Review Board determines in advance that use or disclosure of your health information meets specific criteria specified by law; (b) the researcher signs a legally binding document certifying that he/she will only use the health information to prepare a research protocol or for similar purposes to prepare for a research project and that he/she will maintain the confidentiality of the information and will not remove any of the health information from WT. WT may also disclose health information to a researcher if, (c) it involves health information of deceased patients and the researcher certifies the information is necessary for research purposes; or (d) a researcher obtains data with certain very non-specific geographic identifiers (for example, a zip code) called a limited data set and agrees to use the data only for research or public health purposes. 

We may also create and distribute de-identified health information by removing all individually identifiable information about you. We may contact you, by phone or in writing, to provide appointment reminders or information about treatment, treatment alternatives or other health-related benefits or services, in addition to other communications that may be of interest to you. 

You must always be aware that those individuals that you choose to accompany you into the exam room will be privy to your current and past medical history, exam findings, and diagnoses and treatment. You have given your consent for these individuals to have access to your protected health information by their presence in the exam room. 

The following use and disclosures of PHI will only be made if we receive a written authorization from you:

• Most uses and disclosure of psychotherapy notes;
• Uses and disclosure of your PHI for marketing purposes, including subsidized treatment and health care operations;
• Disclosures that constitute a sale of PHI under HIPAA; and
• Other uses and disclosures not described in this Notice.

You may revoke such authorization in writing and we are required to honor and abide by that written revocation, except to the extent that we have already taken actions relying on your prior authorization.

Your Rights

You have the following rights with respect to your medical information:

• You may request restrictions on certain uses and disclosures of PHI, including those related to treatment, payment, or our health care operations or disclosures to family members, other relatives, close personal friends, or any other person identified by you to be involved in your care. We are, however, not required to honor a request except in limited circumstances, which we shall explain if you ask. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it. If you have paid for health services out of pocket, in full and in advance, and you request that we not disclose PHI related solely to those services to a health insurance plan, we will accommodate your request, except where we are required by law to make a disclosure. 

• You may request to receive confidential communications in a specific way (e.g., at your home or office phone) or to send mail to a different address. We will say yes to all reasonable requests. 

• You may obtain a copy of your medical record by writing to our practice. We will provide you with a copy or a summary of your medical information, usually within 30 days of your request. We may charge a reasonable, cost-based fee for copies. 

• You may amend your medical record if you think it is incorrect or incomplete. You must contact our practice in writing to make this request. We may deny your request, but we will tell you why in writing within 60 days. In such case, you will have the right to submit a statement of disagreement that we must add to your record. 

• You may receive an accounting (list) of disclosures of your PHI for six years prior to the date you ask, who we shared it with, and why. We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting per year for free, but we may charge a reasonable, cost-based fee if you ask for another one within 12 months. 

• You may obtain a paper copy of this Notice upon request. 

• You may choose someone to act for you. If you have given someone a medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI. We will make sure the person has this authority and can act for you before we take any action.  

• You may file a complaint if you believe your privacy rights have been violated. You have the right to file a complaint with our practice by contacting Dr. Brenda F. Cross, Au.D., CCC-A, FAAA, 720 s. Tyler st., Amarillo, TX 79101 in person or by phone at 806-651-5109. 

• You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Our Responsibilities

We are required by law to maintain the privacy and security of your PHI. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We must follow the duties and privacy practices described in this Notice and provide you with a copy of the Notice.

We will not use or share your information other than as described in this Notice unless you tell us we can in writing. If you tell us we can, you may change your mind at anytime. Let us know in writing if you change your mind.

For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to this Notice

The care provided by the WTAMU Speech and Hearing Clinic is a cooperative effort between you and your provider. The clinic staff would like for you to be aware of your rights and responsibilities in this cooperative effort.

You Have the Right to:

• Reasonable and impartial access to available, medically indicated care, treatment, and service within our capability and capacity regardless of race, religion, beliefs, cultural values, gender, age or financial status
• Be treated with respect, consideration, and dignity
• Privacy as appropriate for this setting
• Expect reasonable attempts to communicate in your primary language or manner
• Confidentiality of disclosures and records within the limits of the law
• Receive, to the degree known, complete information concerning your diagnosis, evaluation, treatment, and prognosis
• Participate in decisions involving your care
• A high standard of patient safety while in our care
• Consent to, or refuse, care and/or treatment and be informed of medical consequences
• Select and/or change your health care provider
• Know the name, credentials, and professional status of people serving you
• Review your medical records with a clinician
• Information about our services, the associated costs, and payment policies
• Opt out of participation in experimental research
• Access educational, counseling, protective and advocacy services
• Access emergency services

You Have the Responsibility to:

• Provide proper identification
• Provide complete and accurate information about current condition, medical history, medications, supplements, and any allergies or sensitivities
• Follow the prescribed treatment plan and report any significant changes in symptoms or failure to improve
• Inform a clinician if you do not understand the treatment plan
• Provide a responsible adult that can transport you from the facility and remain with you if directed by your healthcare provider or indicated on discharge instructions
• Inform your clinician of any directive that could affect your care
• Accept financial responsibility for charges incurred
• Be respectful of our other patients, staff, visitors, and WTAMU property
• Keep appointments or cancel the appointment in advance
• Undertake preventive health practices which promote health and safety and delay or avoid disease and injury
• Accept responsibility for outcomes related to refusing treatment or not following the medical team's instructions
• Provide feedback about services and policies.
• Respect the privacy and preserve the confidentiality of other patients and WTAMU Speech and Hearing Clinic staff.

With respect to your health information, you also have the following rights: Right to Inspect and Copy, Right to Request Restrictions, Right to Request, Amendment, Right to Disclosure Accounting, and Right to Request Alternate Methods of Communication.