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We understand that your health information is personal to you, and we are committed to protecting the information about you. This Notice of Privacy Practices (or "Notice") describes how we will use and disclose protected information and data that we receive or create related to your health care.

Our Duties. We are required by law to maintain the privacy of your health information, and to give you this Notice describing our legal duties and privacy practices. We are also required to follow the terms of the Notice currently in effect.

How We May Use And Disclose Health Information About You. We will not use or disclose your health information without your authorization, except in the following situations:

Treatment: We will use and disclose your health information while providing, coordinating or managing your health care. For example, information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will put in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We may also provide other healthcare providers with your information to assist them in treating you.

Payment: We will use and disclose your medical information to obtain or provide compensation or reimbursement for providing your health care. For example, we may send a bill to you or your health plan. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. As another example, we may disclose information about you to your health plan so that the health plan may determine your eligibility for payment for certain benefits.

Health Care Operations: We will use and disclose your health information to deal with certain administrative aspects of your health care, and to manage our business more efficiently. For example, members of our medical staff may use information in your health record to assess the quality of care and outcomes in your case and others like it. This information will then be used in an effort to improve the quality and effectiveness of the healthcare and services we provide.

Business Associates: There are some services provided in our organization through contracts with business associates. We may disclose your health information to our business associates so they can perform the job we've asked them to do. However, we require business associates to take precautions to protect your health information.

Notification of Family: We may use or disclose information to relay or assist in relaying your location and general condition to a family member, personal representative, or other person responsible for your care.

Communication With Family: We may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care.

Receive an accounting of disclosures of your health information. You must submit a request in writing to the contact person indicated below. Not all health information is subject to this request. Your request must state a time period, no longer than 6 years and may not include dates before April 14, 2003. Your request must state how you would like to receive the report (paper, electronically). The first accounting you request within a 12-month period is free. For additional accountings, we may charge you the cost of providing the accounting. We will notify you of this cost and you may choose to withdraw or modify your request before charges are incurred.

Receive a paper copy of this Notice upon request, even if you have agreed to receive the Notice electronically. You may also obtain a copy of this notice at our website, You must submit a request for a paper notice in writing to the privacy officer at 6035 Fairview Rd, Charlotte, NC 28210. All requests to restrict use of your health information for treatment, payment, and health care operations, to inspect and copy health information, to amend your health information, or to receive an accounting of disclosures of health information must be made in writing to the privacy officer at Charlotte Eye Ear Nose and Throat Associates. There may be a fee for the cost of copying your medical record.

Contact Person. Our contact person for all questions, requests, or for further information related to the privacy of your health information is our privacy officer who can be reached in writing at 6035 Fairview Road, Charlotte, NC 28210, or by calling 704/295-3000.

Complaints. If you believe that your privacy rights have been violated, a complaint may be made in writing to our privacy officer at 6035 Fairview Road, Charlotte, NC 28210 or by calling 704/295-3000. You may also submit a complaint to the Office of Civil Rights, The U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth Street, S.W., Atlanta, GA. 30303-8909 or call (404) 562-7886. We will not retaliate against you for filing a complaint.

Changes to This Notice. We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be displayed in our facility.

Notice Effective Date: April 14, 2003

copyright Scott L. Jaben, M.D.