We are committed to protecting the confidentiality of your medical information, and are required by law to do so. Please review our policy and feel free to ask us any further questions you may have.

How will we store your medical records?

Your medical records are electronically stored by scanning into a database called "File Bound." File Bound software files are available to us thru Internet access from our home, as well as our office. It is protected by passwords just as Internet banking accounts are protected. Our computer runs software to protect your information and we use a "firewall" to protect against anyone outside our office who might try to obtain information about you.

How will we use your medical records?

We will use your medical record to provide you with medical services and supplies. When you provide us a letter, we will provide medical records to anyone you specifically request. After being seen in our office, we typically provide your primary care physician (PCP), and any other physician involved in the care of the medical problem(s) we address, with a summary letter of our findings. We do not require a separate consent form to provide this service, and we will assume that you would like us to provide this service unless you tell us otherwise. Your medical records are available to everyone in our office who might need to view them to provide you with our medical services. Everyone in our office has signed a privacy agreement prohibiting him or her from disclosing any information about you to anyone other than your insurance company. Medical information cannot be kept private from anyone who pays for your medical care.

By participating with your insurance company, you give them the right to view your medical record if they choose. Insurance companies commonly request medical records for review to be sure we are doing a good job in providing and documenting our services.

We also use your medical record and phone numbers provided to contact you concerning upcoming appointments, lab results, and other issues concerning your medical care. If you do not wish for us to leave any messages on a voice recording machine you must alert us to your preferences by checking the appropriate box on this information sheet.

Your information may be used in medical journal articles in which we report unusual cases or the results of medical care in our office. Your name would never appear in any such publication.

Your medical information may be disclosed to anyone listed as your emergency contact in situations where you become ill in our office, or if we deem it necessary to contact you immediately but cannot do so with the information you have provided us.

Your information may be shared with persons such as your pharmacists, or medical equipment provider so that we can best meet your needs.

Federal state or local laws may require us to disclose a patient's medical information, such as in cases of suspected child abuse, domestic violence, or workers compensation claims.

Your medical information may be provided to the FDA, (Federal Drug enforcement Agency), concerning problems with medications, or product re-calls. In rare cases, we may be obligated to report medical problems such as communicable diseases to public health officials, or to law enforcement officials in response to a subpoena.

Other physicians may view your medical information if we request them to review our records. If they do so, they will be under the same restrictions for record disclosure as we have implemented in our office.

If we seek to disclose your medical information in a manner not discussed in this notice, you will be contacted for your permission prior to doing so.

What are your rights?

You have the right to view your own medical record. A copy of your record will be provided to you within 72 hours of your request, at no charge. No original medical records exist except in our computer because paper records are destroyed immediately after they are scanned into "File Bound." You have the right to request corrections to your medical record if you feel information is erroneous or incomplete. (This request must be provided in writing.) You have the right to request a list of any medical record disclosures we have made. Please make this request in writing to our privacy officer (Renee Kocian). You have the right to make specific request concerning privacy in the way we contact you, but this must be indicated on your information sheet. You have the right to request restrictions on how your information is used, but any request contrary to standard releases explained in this notice must be provided to us in writing. Unless court ordered, you cannot prevent a divorced spouse from obtaining medical information about his or her child.

We have the right to change our privacy policy at any time. If we do so, we will publish a policy addendum, which will be available to you in our office and published on our website at www.alamoasthma.com.

Complaints concerning your privacy, or any alleged violations of our policy should be addressed to our privacy officer(Renee Kocian). If you do not feel that we have satisfactorily met your privacy needs, you should contact your insurance company to complain or contact Medicare/Medicaid services at (214) 767-6423. We will not retaliate or penalize you in any way for filing a complaint.

Patient's Rights

1. The patient has the right to considerate and respectful care.
2. The patient, if a responsible adult, has the right to be informed about their medical condition so that they can best participate in medical decision making. Alamo Asthma & Allergy has information handouts discussing in detail the following medical problems: Allergic Rhinitis (Hay fever), Sinusitis, Asthma Peak flow monitors, Atopic Dermatitis, Urticaria and Angioedema, Food Allergy, insect allergy, Skin testing, and Allergy shots. These publications are available to you upon request and published on our website at www.alamoasthma.com., and are often provided after our medical evaluations.
3. The patient has the right to know the identity of all persons involved in their medical care. Alamo Asthma & Allergy supports training programs at the University of Texas Health Science Center, and from time to time may host medical students, Physician Assistant students, or medical residents in our office as observers. You have the right to request that they not be present during your evaluation if you choose.
4. The patient has the right to refuse a recommended treatment plan, and to be informed of the possible consequences of refusal. Such situations may result in the physician suggesting a second opinion and/or referring you to another physician.

Patient Responsibility

1. Patients are responsible for providing complete and accurate information concerning prior medical problems and treatment, including reporting all over-the counter medications or supplements used
2. Patients are responsible for participating in medical decision-making, and for requesting additional information when they have questions.
3. Patients are responsible for notifying their physicians immediately if they develop a problem with their medical care.
4. Patients are required to treat the office staff at Alamo Asthma & Allergy with the same courtesy and respect that they are given.
5. Alamo Asthma & Allergy is a non-smoking facility and you should not smoke within 50 feet of any entrance.

Specific directions to safeguard your medical records.

___ Never call me by name from your waiting room. I prefer to be assigned a number.

___ Never contact me at work concerning my medical care or lab / x-ray results.

___ Never leave a phone message or voice mail for me (Contact me by mail only).

___ I have sole custody for my child and do not wish medical information released to my child's other biologic parent. (Court documentation specifying this restriction must be provided.)

• Any person accompanying a minor must have legal guardianship or a letter from the legal guardian before treatment can be rendered to that child.

I have read the Notice of Privacy for Alamo Asthma & Allergy and all questions have been answered to my satisfaction.

Name (Print) _____________________________

Date _______________

Signature _______________________________

Asthma & Allergy Associates
104 Gallery Circle
Suite 126
San Antonio, TX 78258
Tel: 210.499.0033
Fax: 210.404.0926
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