Practice Privacy Notice

Paul G. Pin, M.D.
NOTICE OF PRIVACY PRACTICES

Effective April 1, 2003

Please read this notice carefully. It concerns your individual, private healthcare information and how this information may be used and disclosed by this office. After reviewing this notice you will be asked to consent to the use of your information as described. This consent is voluntary on your part.

1) We have a legal, ethical and moral obligation to protect your confidentiality. Any information about you and/or your family will be held strictly confidential by all employees. No discussions about you outside of the patient care framework will be allowed, and any conversation between staff members that pertains to delivering you quality care will be held in a confidential and professional manner.

2) In order to provide quality care to you, as well as operate this office in an efficient manner, we will need to access your private health care information for purposes of treatment, payment and operations (such as quality assurance). In using this information this office will comply with all state and federal; laws pertaining to your privacy rights, including the privacy and security protections provided to you by the Health Insurance Portability Accountability Act (“HIPAA”).

3) Specifically, we will need to disclose your private information under the following circumstances:

4) Your consent for use and disclosure of information as described may be revoked in writing at any time. Please notify the office/Privacy Officer if you ever decide to revoke your consent.

5) Your specific authorization will be required for the release of any information not included above. Your authorization will need to be in writing and it will be specific to the disclosure requested. Incidences which may require your authorization under the HIPAA regulations include (but are not limited to) some marketing purposes, medical research and legal issues.

6) This office will not release any information other than those incidents described above, unless disclosure is required by law, a court, a legal process or government agencies.

7) Under the HIPAA privacy rule, you will have the right to inspect and copy your protected information, amend your record, have reasonable requests for confidential communications accommodated and may obtain an accounting of disclosures. All other rights afforded to you by state and federal law will be honored as they are created. Please contact the Privacy Officer if you have any question about your rights, the compliance date for this office or any other privacy related questions you may have.

8) This office has policies and procedures in place to facilitate compliance with the law, as well as assure that this office consistently treats you with respect in regards to your privacy and confidentiality. These policies and procedures are available for you to review. If you would like to read them, please notify the Privacy Officer.

9) The Privacy officer is the person in the office responsible for your privacy and the security of your information. Any complaints you or your family may have in this area should be directed to the Privacy Officer. The front office staff will assist you in contacting them.

10) Complaints by patients or family members may also be directed to either the office of Civil Rights or the Secretary of the Department of Health and Human Services.

This office is committed to being in compliance with all state and federal laws protecting personal health care information, including the Final Privacy Rule under the Health Insurance Portability and Accountability Act (HIPAA). In order to coordinate compliance efforts, maintain policies and procedures to assure confidentiality and privacy as well as continually train employees on issues regarding privacy, this office will appoint a Privacy Officer. The Privacy Officer will work in conjunction with the physician, the office’s attorney and any outside consultants who may be retained to assist this office.

1) The Privacy Officer will be the same staff person identified as the Compliance Officer for billing purposes in this office.

2) The Privacy Officer will be responsible for evaluating any and all privacy and confidentiality measures, policies and procedures currently in place, will revise these as necessary to assure full compliance with HIPAA and any other state and federal laws, and will monitor the effectiveness of these measures continually with revision as needed.

3) The Privacy Officer will monitor development of the Security requirements under HIPAA and will initiate any measures necessary for compliance.

4) The Privacy Officer will attend educational seminars as necessary to keep abreast of changes and will in turn educate the physician and staff as necessary.

5) Any and all concerns or complaints of staff regarding privacy, confidentiality and/or security will be brought to the Privacy Officer’s attention.

6) Any patient or family member expressing concern about privacy will be directed to the Privacy Officer.

7) The Privacy Officer will be responsible for ongoing risk assessment and auditing of procedures to assure they are adequately protecting patients’ privacy.

1) The Privacy Officer will assist with the establishment of an annual budget for ongoing staff education regarding privacy and security issues, and will monitor and manage the attendance of appropriate employees at educational seminars or internal classes.

2) At all times the Privacy Officer will keep the physician informed of issues regarding privacy and confidentiality in the office.

3) At all times the Privacy Officer will be expected to communicate freely to the physician about questions and concerns regarding privacy, confidentiality and security.

4) At no time will the Privacy Officer be disciplined or retaliated against for the appropriate communication of concerns or actions taken to protect the integrity of this office (see Open Communication policy and procedure located in this manual).

In keeping with our commitment to comply with all federal and state laws and regulations, this office will invest in continuing education for all of its employees with any access to patients’ personal health care information.

1) The Privacy Officer will estimate educational expenses each year so that amount can be included in the office annual budget, (see Privacy Officer policy & procedure located in this manual).

2) The decision as to which employees will attend which programs will rest entirely with the Privacy Officer. The decision will be based on the needs of the office and not the seniority of staff or any other aspect of employment of an individual employee.

3) Any employee attending an educational program on office time and/or at the expense of the office will be expected to share what he/she learned with other appropriate staff members. The scope, location and timing the of the program will be determined by the Privacy Officer.

4) All staff will comply with any request by their supervisor to redistribute responsibilities in order to facilitate other staff members attending educational programs.

5) All staff will assist as requested in periodic audits of privacy and security measures in this office, and will participate in educational programs conducted by the Privacy Officer (or outside consultants as arranged by the Privacy Officer) based on the findings from those audits.

Our medical records are a fundamental component of delivering quality patient care. The record is a form of communication between health care providers in this office as well as other providers who will care for our patients over the course of their lives. The record will also assist us in remembering important details about our patients’ health concerns over the course of time.

Medical records also have a risk-management function. With the increase in malpractice claims during the mid-1970s, patient charts assumed an important role outside the clinical setting. Although prevention and control are the most important tools a physician has against a potential liability claim complete and comprehensive documentation can mean the difference between a successful defense and an adverse judgment or settlement. In the event of a lawsuit, the medical record provides a historic perspective on treatment that can be measured in terms of standards of care. (Standards of care are the minimum sets of services which should be provided for the treatment of a patient’s condition.) When a physician does not use the standard of care which others in the profession would employ, that physician has breached a duty to the patient. The medical record is a legal document which helps reconstruct the sequence of care.

1) Documentation will include all appropriate facts, findings and observations about an individual’s health history, including past and present illnesses, examinations, tests, treatments and outcomes.

2) The structure of medical records in this facility will be consistent, and in a format that allows the physician to access it easily and quickly.

3) Documentation will also be in keeping with billing requirements of third-party payers, including CPT/ICD-9 codes.

4) Records will adequately and accurately record the site of the service, the medical necessity and appropriateness of the diagnostic and/or therapeutic service provided, the quality of care delivered and the outcomes related to delivered care.

6) All entries will include the initials of the person making the entry, as well as the date of the entry.

7) Each patient will have a separate record. Family members will not be grouped into one record.

8) Every record will include documentation of any and all complaints by the patient related to any medical condition and/or treatment, examinations/assessments, office visits, and results from specialized testing and plans of treatment.

10) No entry will ever be made that reflects a negative judgment about a patient and/or a family member.

11) No record or any entry therein will be altered, erased, obliterated, deleted, removed or destroyed under any circumstances.

12) If an erroneous entry is made a single line should be placed through the error, initialed by the employee making the notation with the date of the correction above his/her initials.

13) “White Out” and other obliterating materials are not allowed for use in this facilities records.

14) Employees of this facility will always keep in mind that a medical record is a legal document, and that every medical record must be complete, detailed and accurate. Any falsification of the record will be grounds for possible legal action by state regulatory agencies up to and including revocation of licensure. In addition falsification or other inappropriate behavior regarding medical records, including the inappropriate divulging of confidential information, may result in disciplinary action including termination of employment.

The following standards should be considered in order to ensure complete and proper documentation of all patient-related issues (this list should not be considered to be definitive or all-inclusive).

2) Failure to return for follow-up visits as well as any attempts to contact the patient to reschedule should be documented.

3) Cancellations or missed appointments should be documented, including the reason for the missed treatment, if provided.

4) Any discussion held over the phone and all prescription refills should be documented.

5) To improve efficiency and minimize the possibility of losing critical information, any patient medical record will contain medical information and limited financial information.

6) Patient’s records should be filed alphabetically. Additionally, all information in patients’ medical records will be arranged in a uniform manner consistent with this office’s guidelines.

7) In addition to the required medical records documentation procedures, patients presented with special conditions (e.g., allergies, precautions, contraindications, special instructions, etc.) will have these special conditions posted on the outside of the front cover of their medical record. (Patient confidentiality WILL NOT be compromised while meeting this standard).

8) If a cardiovascular complication exists, the patient’s cardiovascular status before, during and after any procedure should be documented.

9) Patients will be given access to their permanent medical record according to federal and state regulations.

We have a legal, ethical and moral obligation to protect the confidentiality of our patients. All information about any patient will be held strictly confidential by all employees. No discussion of patients outside of the patient care framework will be allowed, and any conversation between staff members that is directed at delivering quality patient care will be held in a confidential and professional manner.

1) Should a patient inquire about the diagnosis or any other personal information regarding another patient, the inquiring patient will be told, “I can’t discuss that due to patient confidentiality ”.

2) All patient records will be secured in the allocated place within this office. Staff members will ensure, at all times, that conversations regarding patients are not overheard by others.

3) Any and all information gathered or heard, officially or unofficially, about a patient shall be construed as confidential. Release of the aforementioned information by an employee to another patient, a fellow employee or any unauthorized person shall be regarded as a breach of confidence and grounds for immediate dismissal.

4) Physician’s prescription pads will be considered to be a record or document and as such will be stored and secured in the same manner as any other medical record of this office. All prescription pads will be stored and secured out of view at all times, especially during normal business hours.

5) Records will never be left where they are able to be read by any unauthorized person.

6) All treating physicians will be given appropriate access to a patient’s medical record in keeping with the delivery of quality patient care (see Release of Medical Records policy and procedure including in this manual). This will include the appropriate sharing of medical records with all consulting physicians.

7) Records may be reviewed by the patient by a parent of a minor (under most circumstances) and people who have a legal duty/authority such as a guardian or a person with a legal right under a effective Durable Power of Attorney. These people will still be asked to sign an appropriate Release of Medical Record form (see Release of Medical Records policy and procedure included in this manual). No other persons will be allowed access to medical records.

8) Information concerning patients is strictly confidential and must not be discussed with unauthorized persons either inside or outside the office.

In keeping with our duty to protect our patient’s confidentiality (see Confidentiality of Medical Records policy & procedure included in this manual), this facility will not release any medical record without strict adherence to the following procedure.

1) In keeping with Texas law, original medical records are the property of the treating physician, and as such will not be released from this facility unless in accordance with a court order, subpoena or statute. Original medical records are never allowed to leave this facility without prior authorization and approval by the treating physician.

2) This facility recognizes the right of patients to have a copy of their medical record forwarded to themselves, another physician, or an attorney for legal purposes.

3) In keeping with our duty to be assured that we are complying with the patient’s wishes, oral requests for the release of medical records will not be honored.

4) Any patient requesting release of their medical records, even to themselves, will complete the authorization for release of medical records form produced by this office.

5) A parent or legal guardian will be required to sign the authorization for release of medical records form if the patient is a minor. A legal guardian must sign if the patient has been adjudicated incompetent to manage his or her personal affairs. An attorney appointed for the patient, or a legally recognized representative for a deceased patient may also sign the release of medical records form. No other persons will be permitted to sign in lieu of patients in this office without a court order or similar legal directive.

6) No information regarding a patient will be accessible to anyone who is not authorized to obtain such information unless the patient or legal representative has expressively consented, in writing to such release of information.

7) Prior to any records being released, a copy of the written release of medical records form must be retained and placed in the patient’s permanent medical record.

8) This office will do everything within its powers to assure that no forgeries or other illegal requests for release of medical records are honored, but cannot guarantee that such fraudulent requests will not pass reasonable scrutiny and procedure.

9) The patient or other person authorized to consent, has the right to withdraw consent to the release of any information. Such withdrawal must be in writing. No information should be released after consent has been withdrawn.

10) Medical records will be faxed from this office when the request is consistent with delivering quality patient care. Following an appropriate request for medical records the requested information will be faxed with, the following precautions being taken:

11) Faxing medical information will comply with the requirements of the Medical Practice Act relating to consent for release of confidential information when transmitting any confidential or physician-patient communications, or privileged medical records.

12) The attached confidential fax transmission cover sheet will always be utilized.

13) Any fee or charge for copying, mailing or otherwise complying with an appropriate request for the release of medical records will be accordance with limits set by the Texas State Board of Medical Examiners.

This office will maintain all medical records in accordance with all applicable federal, state and local laws, statutes and ordinances.

1) In order to protect the confidentiality of our records, no unauthorized access will be permitted. Records will be restricted to employees with a specific work related need to view the records, and those employees will only access those portions of the record applicable to their duties. No other employee access will be permitted; violation of this principle will result in appropriate disciplinary action.

2) In keeping with the 1997 ruling by the Texas State Board of Medical Examiners, all records in this office will be saved for seven (7) years after the last date of treatment and/or death of the patient.

3) In addition, as per the TSBME ruling, all pediatric records will be saved until the patient reaches twenty one (21) years of age, or seven (7) years, whichever is longer.

4) No record will be destroyed by this office, even if the record retention requirement set by the Texas State Board of Medical Examiners has expired, if that record is related to any civil, criminal or administrative proceeding and it is known by this office and/or the physician that the proceeding has not been finally resolved.

5) This facility will retain records longer than seven (7) years under any circumstances imposed by other federal or state statutes or regulations.

6) Destruction of medical records will be performed exclusively by means which will maintain patient confidentiality, such as shredding or incineration. This process will be under the supervision and the responsibility of the Office Manager.

Communication is a key to quality patient care as well as customer satisfaction. Anyone contacting this office by phone will find this office to be courteous, efficient and professional.

2) Appropriate training/disciplinary procedures will be activated if phone calls are not being answered in time, and staffing will be adjusted accordingly.

3) If a phone is answered but the caller must wait for the completion of another call, the staff member will answer and ask, “Can you please hold?” NO CALLER WILL BE PUT ON HOLD UNTIL THE QUESTION IS ANSWERED AFFIRMATIVELY. This is critically important as patients may be calling in an emergency situation.

4) No person will be placed on hold by the front office for more than four (4) minutes before finding out who is calling, and for what purpose.

5) Calls for appointments will addressed in accordance with the Appointments policy & procedure (located in this manual).

6) Calls regarding care, treatment, or questions and concerns about symptoms will be forwarded to the physician.

7) The patient will always be given the opportunity to speak to the physician, with assurances that the doctor will return the call at his earliest convenience.

8) If the office has any concern regarding whether the caller needs immediate evaluation by the physician, the physician will be interrupted and given all the appropriate information in order to address the patient concern immediately.

9) It is the policy of our office to only contact patients at home, unless a specific alternate request is made. In attempting to return phone messages, supply information about treatment, or notify patients of upcoming appointments our office will call the patient’s home and leave a message either with a person or on the patient’s answering machine. At no time will our office attempt to contact a patient at work unless specifically instructed to do so by the patient themselves.

Protecting patient confidentiality is one of the primary responsibilities of all employees of this office. Even well intentioned inquires must not be answered in a manner that violates our patients’ confidentiality.

1) Telephone calls are to be answered promptly and courteously (see Telephone Procedures policy located in this manual), but information is to be given out very cautiously.

2) Ethical and legal restrictions on the dissemination of medical information are numerous. When in doubt it is the office policy to never give out any information.

4) Friends or Relatives – Restrict information given to callers. Never divulge information regarding diagnosis or treatment. Offer to refer inquiries to the patient, family members, or the physician as appropriate.

7) Physicians – Release required information only if the physician is participating in the diagnosis, examination and treatment of the patient.

8) Any inquirer should be asked to identify himself/herself and should be requested to state his or her purpose for the inquiry. When in doubt, no information should be released, and the inquirer should be referred to the Office Manager.

Integrity is important to this office. We are committed to follow ethical guidelines as well as all legal requirements from federal, state and local authorities. In recognition of this commitment we urge all employees to notify the Privacy Officer if they are ever aware that this standard of conduct is not being met by any person in this office. (See also the Privacy policy & procedure, located in this manual).

1) Should any employee become aware of any impropriety regarding this office’s duty to protect our patients’ privacy & confidentiality, that person must contact the Privacy Officer.

2) Concerns about the privacy and security of patients’ health information may also be conveyed by contacting the Privacy Officer at home.

3) If the employee’s concern is not sufficiently resolved by the Privacy Officer, the employee should contact Dr. Pin.

4) At all times the confidentiality of the employee will be of the utmost importance, but will not interfere with necessary investigations and actions that may occur as a result of the information.

5) Under no circumstances will any administrative action be taken to retaliate against any employee making any allegation of impropriety, even if their concerns prove to be unjustified.

6) Appropriate accommodations will be made to the extent possible in order to alleviate tensions between staff members that may result from such reporting.

7) Under no circumstances will harassment of an employee due to his/her appropriately reporting concerns be tolerated. Other employees face termination of employment if retaliatory words or acts are evident.

Complaints may arise under a variety of circumstances in any clinical setting. The purpose of this policy is to anticipate complaints and provide a coherent, concise means to respond in order to preserve patient confidence and satisfaction.

1) Listen – In order to truly listen you must give your undivided attention. Stop what you are doing. If you are on the phone make appropriate responses so the patient knows you are listening. Do not argue with the patient or interrupt with explanations. Listen without attributing fault.

2) Empathize – Put yourself in the customer’s place. Offer a statement of empathy (e.g., I’m sorry that...”, or “I understand that...”). Do so without agreeing to guilt on your part or on behalf of the office. Extend understanding without agreement.

3) Inquire – Gain as much information as you can concerning the problem to assist with your decision for the best route to handle the complaint. Be sure the patient knows you take his or her concern seriously.

4) Act – Explain suggested solutions concerning those things that you can do. Get his or her approval on the recommended action (e.g., “I will contact... and ask them to get back to you”). If there isn’t any action that is immediately apparent assure the patient that the appropriate person will be informed and that the patient can expect a response back.

5) Conclude – Thank the customer for taking the time to notify you of their concern/complaint. Leave them with a clear understanding that patient satisfaction is a critical component of quality patient care in our office. Ask if you can help with anything else.

1) Record complaint as outlined above. Report the complaint, any action you have taken in response to the complaint, and the status of the complaint (i.e. resolved, still needs action, needs input from privacy officer, etc.).

2) Contact patient to assure him/her that complaint was received. Inform patient of the results as appropriate. Provide addresses of appropriate individuals or agencies to patient or patient representative as appropriate.

3) Review findings and suggested changes in clinical practice, employee policies, etc.

4) Have copy of complaint, incident reports and/or other documentation stored appropriately.

We have a legal, ethical and moral duty to protect our patient’s rights. At the same time, our patients have a responsibility to participate in their care in an appropriate, reasonable manner.

1) The notice of Patient Rights [attached] will be available in each treatment area as well as the waiting room of this office.

2) A copy of the Patient Rights form will be provided to any patient, family member or visitor upon request;

3) The notice of Patient Responsibilities [attached] will be available in each treatment area as well as the waiting room of this office.

4) A copy of the Patient Responsibilities form will be provided to any patient, family member or visitor upon request;

5) All employees will be familiar with these documents through training in the initial orientation process as well as annual ongoing in-service education at the direction of the Office Manager.

This form is meant to inform you, the patient, as well as your family that you have rights and responsibilities while undergoing medical care in our office. If there are any questions regarding the contents of this form please notify any staff member.

1) Access to Care – Individuals shall be accorded impartial access to treatment or accommodations as to his or her requests and needs for treatment or service that are within the office’s capacity, availability, stated mission and applicable law and regulation, regardless of race, creed, sex, national origin, religion, disability/handicap or source of payment of services.

2) Respect and Dignity – Every individual, whether adult, adolescent or newborn, has the right to considerate, respectful care/services at all times and under all circumstances, with recognition of his or her personal dignity and his or her psycho social, spiritual and cultural variables that influence the perceptions of illness.

3) Privacy and Confidentiality – The patient or his or her parent or legally designated representative has the right, within the law, to personal and informational privacy, as manifested with the right to:

4) Personal Safety – The patient, whether adult, adolescent or newborn, has the right to expect reasonable safety insofar as the office practices and environment are concerned.

5) Identity – The patient of his or her parent or legally designated representative has the right to know the identity and professional status of the individuals providing service to the patient, and to know which physician is primarily responsible for his or her care/services. This includes the right to know of the existence of any professional relationship among individuals who are treating him or her, as well as the relationship of the office to any other health care/services involved in his or her care. Participation by patients in clinical training programs or in the gathering of data for research purposes should be voluntary.

6) Information – The patient or his or her parent or legally designated representative has the right to obtain from the practitioner responsible for coordination of his or her care/services complete and current information concerning his or her diagnosis (to the degree known), any treatment and any known prognosis. This information should be communicated in terms the patient or his or her parent or legal designated representative can reasonably be expected to understand. When it is not medically advisable to give such information to the patient, the information should be made available to a legally authorized individual.

7) Consent – The patient or his or her parent or legally designated representative has the right to the information necessary to enable him or her, in collaboration with the physician, to make treatment decisions involving his or her health care/services that reflect his of her wishes. To the degree possible, this should be based on a clear, concise explanation of his or her condition and of all proposed technical side effects, problems related to recuperation, and probability of success. The patient should not be subjected to any procedure without voluntary, competent consent by the individual or by his or her legally designated representative. Where a medically significant need for care/services or treatment exists, the patient or his or her parent or legally designated representative shall be so informed.

8) Consultation – The patient or his or her legally designated representative has the right to accept medical care/services or to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal. When refusal of treatment by the patient or his or her parent or legally designated representative prevents the provision of appropriate care/services in accordance with ethical and professional standards, the relationship with the patient may be terminated upon reasonable notice.

9) Transfer and Continuity of Care – A patient has the right to expect that the office will give necessary health services to the best of its ability. Treatment, referral or transfer may be recommended. If transfer is recommended or requested, the patient will be informed of risks, benefits and alternatives.

10) Charges – Regardless of the source of payment for the individual’s care/services, the patient or his or her parent or legally designated representative has the right to request and receive an itemized and detailed explanation of his or her total bill for services rendered in the office.

11) Delineation of Patient’s Rights – The rights of the patient may be delineated on behalf of the patient, to the extent permitted by law, to the patient’s guardian, next of kin or legally authorized responsible person if the patient provided the patient:

12) Rules and Regulations – The patient or his or her parent or legally designated representative should be informed of the office rules and regulations applicable to his or her conduct as a patient. Patients are entitled to information about the mechanism for the initiation, review and resolution of patient complaints.

This form is meant to inform you, the patient, as well as your family that in addition to rights, you have responsibilities while undergoing medical care in our office. If there are any questions regarding the contents of this form please notify any staff member.

1) Keep Your Health Care Providers Accurately Informed – A patient or his or her parent or legally designated representative has the responsibility to provide, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to his or her health. He or she has the responsibility to report unexpected changes in his or her condition to the physician. A patient or his or her parent or legally designated representative is responsible for making it known whether he or she comprehends a contemplated course of action and what is expected of him or her.

2) Following Your Treatment Plan – A patient or his or her parent or legally designated representative is responsible for following the treatment plan recommended by the practitioner primarily responsible for the patient’s care/services. This may include following the instructions of office personnel as they carry out the coordinated plan of care/services and implement the physician’s orders.

3) Keep Your Appointments – The patient is responsible for keeping appointments and, when unable to do so for any reason, for notifying our office.

4) Be Responsible For Any Decision You Make Not To Follow Your Treatment Plan, And Keep Your Health Care Practitioners Informed About Your Decision(s) – The patient or his or her parent or legally designated representative is responsible for his or her actions if he or she refuses treatment or does not follow the physician’s instructions. If the patient cannot follow through with the treatment, he or she is responsible for informing the physician.

1) Be Responsible For Your Financial Obligations – The patient or his or her parent or legally designated representative is responsible for assuring that the financial obligations of his or her health care/services are fulfilled as promptly as possible. The patient is responsible for providing information for insurance.

2) Comply With The Rules Of This Office Regarding Patient Care and The Conduct of Our Patients/Visitors – The patient or his or her parent or legally designated representative is responsible for following office rules and regulations affecting patient care/services and conduct.

3) Be Considerate of Others – The patient or his or her parent or legally designated representative is responsible for being considerate of the rights of other patients and personnel, and for assisting in the control of noise, smoking and the number of visitors. The patient is responsible for being respectful of the property of other persons and of the office.

4) Be Responsible For Your Own Lifestyle Choices – A patient’s health depends not just on his or her care/services but, in the long term, on the decisions he or she makes in daily life. He or she is responsible for recognizing the effect of lifestyle on his or her personal life.

The office recognizes the right of every patient to participate in the development of their treatment plan and to consent to treatment before it is initiated. We also understand that consent requires the patient be adequately informed and give consent freely and without any duress or pressure. Information given to the concenter should include the following: diagnosis of condition, nature and purpose of the proposed treatment, risks and ramifications involved, alternative methods of treatment, and the prognosis if the procedure is not performed.

1) The patient, or his or her parent or legally designated representative, has the right to an individualized treatment plan and to participate in the development of that plan.

2) The patient, or his or her parent or legally designated representative, has the right to the information necessary to enable him or her, in collaboration with the physician to make treatment decisions involving his or her health care/services that reflect his or her wishes.

3) The staff of this office will assist in the proper education of the patient (and or representative) to facilitate informed consent. Educational materials such as brochures, pamphlets and other aids will be utilized as available, but they will never replace the importance of discussion of treatment with a patient and answering all of his/her questions. Educational efforts will be documented in the patients chart (see attached Patient Education form).

4) The staff will participate in the education of patients (and/or their representatives) as appropriate, but the responsibility for assuring consent is informed and granted remains with the treating physician.

5) Consent, to the degree possible, will be based on a clear, concise explanation of:

6) The patient will not be subjected to any procedure without voluntary, competent consent by the individual or that of his or her parent or legally designated representative.

9) At least 16 years old, lives apart from his or her parents, and manages his or her own financial affairs.

10) Consenting to the diagnosis and treatment of any infectious, contagious or communicable disease which is reportable to the Texas Department of Health.

11) The patient, or his or her parent or legally designated representative, has the right to know who is responsible for authorizing and performing the procedures or treatment.

12) The patient, or his or her parent or legally designated representative, shall be informed if the office proposes to engage in research/educational projects affecting his or her care/services or treatment. If the patient chooses not to take part, he or she shall receive the most effective care/services the office otherwise provides.

13) The patient, or his or her parent or legally designated representative, has the right to accept medical care/services or to refuse treatment to the extent permitted by law, and be informed of the medical consequences of such refusal. When refusal of treatment by the patient or his or her parent or legally designated representative prevents the provision of appropriate care/services in accordance with ethical and professional standards, the relationship with the patient may be terminated upon reasonable notice (see Termination of Physician/Patient Relationship policy & procedure located in this manual).

The purpose of this policy is to make certain that methods and procedures are in place to ensure effective communication with persons of limited English-proficiency so that they will be afforded equal access to the services provided by our office.

1) The office shall provide for communication with limited English-proficient persons, including current and prospective patients, family, interested persons, et al., to ensure them an equal opportunity to benefit from services.

2) Any information about services, benefits, consent forms waivers of rights, financial obligations, etc., will be communicated to limited English-proficient persons in a language which they understand.

3) When a translator is needed, the office staff is responsible for contacting a translator who speaks the needed language. If unable to locate a translator the office will utilize the AT & T translator operator.

4) Family members will never be used as translators during the normal course of treatment without the patient’s consent, as it is impossible to protect the patient’s confidentiality and privacy when his/her family members are involved in this manner.

Paul G. Pin, M.D.
3600 Gaston
Barnett Tower, Suite 410
Dallas, Texas 75246
214-827-2530