BAYLOR SPEECH AND HEARING CLINIC PAPERWORK PACKET
These instructions will help you complete this paperwork packet prior to your first appointment at the
clinic.
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The first 7 pages are case history information.
The Notice of Privacy Practices is yours to keep.
The remaining pages are for records to Baylor or from Baylor. These stay in the client file. You
only need to complete the highlighted areas on these pages.
Evaluation Fees:
Speech Evaluation
$200
Language and Literacy Evaluation
$350
Medicare, Medicaid, or Chips card must be presented if client is enrolled in program. Please feel free to
call me at (254)710-2568 if you have any questions about the paperwork.
Be sure to bring the completed packet with you on the day of the evaluation. Thank you and we look
forward to seeing you soon!
If therapy is recommended, you will be placed on a waiting list IF a placement cannot be made
immediately.
Temporary Parking Pass
Visitors to Baylor University must have a Temporary Parking Pass displayed on your vehicle in Visitor’s
Parking Lots. If you have a speech/language or audiology evaluation scheduled, call Parking Services at
(254) 710-7275 to set up a visitor parking account, or you can call me at (254) 710-2568. Give me your
vehicle information and I’ll email the form to Parking Services and have your temporary pass at my desk
the day of your visit to Baylor Speech, Language & Hearing Clinic.
Melody Moon
Administrative Associate
Baylor Speech, Language & Hearing Clinic
One Bear Place #97332
Waco, TX 76798-7332
Phone: (254) 710-2568
Fax: (254) 710-1156
Email Address: Melody_Moon@baylor.edu
Baylor University Speech-Hearing Language Clinic
Case History Form
This information is strictly confidential and cannot be provided to individuals or agencies
without written consent.
CHILD HISTORY
Date: _______________
Identifying Information
Child’s Name: ____________________________________________________________
Age: ________ DOB: ____________ Sex: Male Female Current grade in school: __________
Home Street Address: _________________________________ City: ______________________
State: _________________ Zip code:_____________
Mother’s Name: _______________________________ Age: _______________
Address:__________________________________________________________
Home phone: ______________________ Work phone:________________ Cell phone: ______________
Occupation: _________________________ Email: _______________________
Father’s Name: _________________________________ Age: ______________
Address:__________________________________________________________
Home phone: ______________________ Work phone:________________ Cell phone: ______________
Occupation: _________________________ Email: ___________________________
Guardian Name: _______________________________ Age: _______________
Address:__________________________________________________________
Home phone: ______________________ Work phone:___________________
Cell phone: ___________________ Occupation: _________________________
Home Language ____________________ Other languages spoken in the home ___________
Have you been seen at this facility previously? _________ Date/s: __________________
Does your child have hearing problems? Y N If yes, what is being done? _______________________
_____________________________________________________________________________________
Does your child have vision difficulties? Y N If yes, what is being done? _________________________
_____________________________________________________________________________________
I. Statement of Problem/ Referral:
MUST ANSWER THESE QUESTIONS
Describe as completely as possible the speech, language, and hearing problem. _____________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Referral Source: _______________________________________________________________________
When was the problem first noticed? _______________________________________________________
_____________________________________________________________________________________
How has the problem changed since you first noticed it? ________________________________________
_____________________________________________________________________________________
What has been done about it? Has this helped? _______________________________________________
_____________________________________________________________________________________
What do you think caused the problem? _____________________________________________________
_____________________________________________________________________________________
What do you hope to learn from this evaluation and what do you think should be done?
_____________________________________________________________________________________
_____________________________________________________________________________________
Can you understand your child’s speech? ____________________________________________________
Name others who have difficulty understanding speech _________________________________________
Is your child aware of the problem? Explain __________________________________________________
_____________________________________________________________________________________
Tell your child’s reaction to his own speech difficulties __________________________________________
Tell the reaction of you and other family members to the problem__________________________________
_____________________________________________________________________________________
Family history of speech/language problems _________________________________________________
_____________________________________________________________________________________
What do you do to help your child? _________________________________________________________
If your child has difficulty producing sounds, which ones are problems? ____________________________
Does your child understand words spoken to him/her? __________________________________________
Does he/she understand conversation? _____________________________________________________
Does your child repeat words or show difficulty with breaks in his speech? __________________________
_____________________________________________________________________________________
Does your child stutter: none _____ rarely _____ occasionally _____ frequently _____
If yes, then how long has this been a problem? _______________________________________________
Does your child have an unusual voice quality? (loud, soft, hoarse, nasal) __________________________
Give other information to explain your child’s communication problem ______________________________
_____________________________________________________________________________________
Tell us more about previous evaluations or services provided with approximate dates:
Speech therapy: ______________
Physical therapy: ____________________
Occupational therapy: __________
Cook’s Children’s Hospital, Dallas
Scottish Rite Hospital, Dallas
Callier Center, Dallas
Klaras Center, Waco
MHMR, Waco/other
Child Protective Services
Counseling services
Psychological services
Public school
Audiology
Other
List diagnosis/es: ____________________________________________________________
Describe services: __________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Family
Others living in the home:
Name
Age
Relationship
Diagnosed Speech/Learning Problem
Is the child adopted? ______________________ Age adopted _________________
This information is important for diagnosis and treatment. Please answer carefully and specifically.
Histories
Prenatal and Birth History : Check if they apply
A. Pregnancy
Full term ________
Normal Birth _____
If problems existed, please check those that apply:
Excessive bleeding
German measles
Mother – bed rest
High blood pressure
Diabetes
Smoking
Previous miscarriage
RH incompatibility
Brain injury
Toxemia
X-ray treatment
Serious accident
Premature membrane/
Mother- alcohol use /
Mother – drug
Rupture
abuse
use / abuse
Comments: ____________________________________________________________________
_______________________________________________________________________
B. Birth
Full term ________
Normal Birth _____
Length of labor _______ Birth weight ______ Birth length _____
If problems existed, please check those that apply:
Vaginal birth
C-Section
Breach
Breathing problems
Jaundice
Extended hospital stay
Incubator
Cyanosis
Seizures
Injury
Deformity
Infection
Anoxia
Difficult delivery
Feeding difficulty
Cleft/ lip palate
Swallowing/sucking
Physical Abnormalities
problems
Specify _____________
Explain any complication related to birth _____________________________________________
_____________________________________________________________________________
III. Child Development
Your general impression of the child’s overall development:
slow _____
normal_____
advanced_____
A. Motor development
slow _____
normal ____
advanced ____
Give age:
Age sat alone
Age crawled
Age reach and grasp
Age walked
Age potty trained
Age feed self
Age dressed self
Explain/note any motor difficulties: __________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
B. Emotional and Behavioral
Check if they apply:
Behavior
Home
School
Other
Compliant behavior
Learning problems
High activity level for age
Difficulty following directions
Difficulty maintaining attention
Impulsivity (not thinking before acting)
Difficulty playing with others
Prefers to play by him/herself
Difficulty getting along with peers
Problems with adult authority
Aggressive
Behavior problems
Friendly, outgoing
Shy
Easily distracted by:
Overly sensitive to stimuli
Low response to stimuli
Toys or activities the child prefers to play with: __________________________________________
_______________________________________________________________________________
Describe any discipline difficulties: ______________________________________________________
How do you discipline at home? _____________________________________________________
Explain current significant family stresses _______________________________________________
Previous family stressors ___________________________________________________________
C. Speech and Language Development
Fill in age that behaviors began:
Cooing sounds
First words
Short sentences
Vocal play/babbling
Phrases
Tell the way your child lets you know what he/she wants at this time
Eye gaze
Pointing
Gestures
Moves other’s hand/body
Single words
2-3 word phrases
Crying
Vocalizing
Complex sentences
Signs / augmentative
IV. Medical History
Illnesses/Conditions
Check those that apply and fill in approximate date/s:
Allergies
Hearing aids- which ear R L
Amputations
Hearing amplification device
Asthma
Hearing problems
Attention Deficit Disorder
High fevers
Augmentative communication device
Hoarseness
Autism
Lengthy medication treatment
Auto accidents
Measles
Behavior problems
MR
Braces
Nightmares
Brain injury
Obturator
Cerebral palsy
Other surgery:
Chickenpox
Hospitalization for ________________
Cleft palate/submucous cleft
Pervasive Developmental Disorder
Cochlear implant
Physical Abnormalities
Convulsions
Poor appetite
Digestive problems
Schizophrenia
Down’s Syndrome
School phobia
Drooling
Seizures
Dyslexia
Sensori-integration disorder
Ear infections
Serious injury:
Emotional problems
Stuttering
Encephalitis
Swallowing problems
Falls frequently/balance
Syndrome (other): ________________
Feeding/eating problems
Thumbsucking
Fragile X Chromosome Disorder
Tongue-tie
Frequent colds
Tonsillectomy and/or Adenoidectomy
Glasses
Tubes in ears
Hand preference R L
Vision problems
Head injury
Vocal nodules
Is the child currently under a doctor’s care? Give diagnosis and physician’s names:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What current medication is he/she taking? _______________________________________________
_________________________________________________________________________________
Hospitalizations: date(s) /cause(s) _____________________________________________________
_________________________________________________________________________________
V. School History
Schools attended:
School/
Grade
Name of
Academic
Academic
Dates
Level
School
Strengths
Weaknesses
Day care/Nursery
Preschool
PPCD
Kindergarten
Elementary
Middle School
High School
Private
Homeschooled
Has your child been held back or repeated a grade? Y N
Explain _______________________
________________________________________________________________________________
Currently, what are your child’s grades? ________________________________________________
Has your child been tested at school to address developmental, learning or speech-lang. difficulties? Y N
If yes, explain Results: _________________________________________________________________
What special education services has your child received for difficulties in school? (check all that apply)
Speech therapy ___
resource ___
self contained ____ OT ____
Other: _________
What modifications have been used in school to support your child? _______________________________
_____________________________________________________________________________________
How does he/she feel about school?_____________________________________________________
Does your child learn easier for a particular style of learning? Explain:
Auditory _________________________________________________________________
Visual _________________________________________________________________
Both _________________________________________________________________
Other activities your child is involved in outside of school (sports, lessons, church, tutoring, Scouts, etc.):
______________________________________________________________________________
______________________________________________________________________________
Please give any additional information that will help us in evaluating your child: _________________
________________________________________________________________________________
Child’s primary physician
Name_____________________________________
Address _____________________________________________________
Phone Number_______________________________
Diagnosis ____________________________________________________
Other professionals who have treated/evaluated the child
Name/Position_________________________________________________
Address______________________________________________________
Phone Number_______________________________
Diagnosis ____________________________________________________
I wish reports to be sent to these persons/agencies:
Name _______________________________________________________
Title _______________________________________________________
Address _____________________________________________________
Phone ________________________
Name _______________________________________________________
Title _______________________________________________________
Address _____________________________________________________
Phone ________________________
___________________________________
Signature of person completing this form
Reviewed January 11, 2007
__________________
Relationship to child
_____________
Date
Baylor University Speech and Hearing Clinic
AUTHORIZATION TO RELEASE PROTECTED HEALTH RECORDS
I, ________________________________ who resides at ______________________________
In the city of ___________________ in the state of __________________ hereby authorize:
Baylor University Speech and Hearing Clinic
PO Box 97332
Waco, Texas 76798-7332
to disclose the following specific health information by
□ mail or
□ fax or
□ email to:
Name: ________________________________________________________________
Address: ______________________________________________________________
City, St., Zip: ___________________________________________________________
from the Health Records of:
Name: ________________________________________________________________
(NAME OF INDIVIDUAL WHOSE RECORD IS BEING DISCLOSED)
Address: ______________________________________________________________
City, St., Zip: ___________________________________________________________
For the purpose of: ____________________________________________________________
My authorization extends only to those data elements/documents initialed below:
______________ Diagnostic Reports
______________ Hearing Reports
______________ Session Reports
______________ Test Results
______________ All of the above
______________ Other (must be specific) ________________________________________
________________________________________
AUTHORIZATION TO RELEASE PROTECTED HEALTH RECORDS
PAGE 2
This authorization is given freely with the understanding that:
1. Any and all records, whether written or oral or in electronic format, are confidential
and cannot be disclosed without my prior written authorization, expect as otherwise
provided by law.
2. A photocopy or fax of this authorization is as valid as this original.
3. I may revoke this authorization at any time, except where information has already
been released. This authorization is valid for a sixty (60) day period from the date it
is signed, or sooner if noted below.
4. Baylor University, its employees and officers are hereby released from any legal
responsibility or liability for disclosure of the above information to the extent indicated
and authorized herein.
5. Treatment, payment, enrollment or eligibility for benefits may not be conditioned
upon obtaining this authorization.
6. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected.
___________________________________
PATIENT’S SIGNATURE (OR GUARDIAN, IF A MINOR)
__________________________________
PATIENT’S NAME PRINTED
__________________________________
WITNESS
___________________________________
DATE
___________________________________
EXPIRATION DATE (IF OTHER THAN ONE YEAR FROM
ABOVE DATE)
___________________________________
DATE
Baylor University
Department of Communication Sciences and Disorders
P.O. Box 97332
Waco, TX 76798-7332
Release of Information
Date: _______________
RE: Name: _________________________________________
DOB: __________________
To Whom It May Concern:
I hereby grant permission for _________________________________________ to disclose and deliver
(name of school/institution or above agencies)
any information requested by __________________________________________ concerning my
(name of school/institution)
son/daughter ___________________________________________________.
This information may include case history, results of examination, impressions, and recommendations
that might benefit __________________________________________ in treating
(name of school/institution)
_________________________________ speech and communication disorder.
1. Any and all records, whether written or oral or in electronic format, are confidential
and cannot be disclosed without my prior written authorization, except as otherwise
provided by law.
2. A photocopy or fax of this authorization is as valid as this original.
3. I may revoke this authorization at any time, except where information has already
been released. This authorization is valid for a sixty (60) day period from the date it
is signed, or sooner if noted below.
4. Baylor University, its employees and officers are hereby released from any legal
responsibility or liability for disclosure of the above information to the extent indicated
and authorized herein.
5. Treatment, payment, enrollment or eligibility for benefits may not be conditioned
upon obtaining this authorization.
6. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected.
___________________________________________
Signature
___________________________________________
Relationship
Consent Agreement
I understand that the Baylor University Speech and Hearing Clinic, hereafter referred to
as the Center, is operated as a training center for speech-language pathologists and
that all therapy conducted at the Center is supervised by a licensed clinician and that all
lessons may be observed by students in training or by students who may be interested
in majoring in this field.
I further understand that many of the lessons are recorded by television or on tape
recorder and that these lessons may be played in speech therapy classes as examples
of speech, language, and hearing disorders or may be presented at professional
meetings of doctors, dentists, psychologists or speech clinicians or other professional
groups and that these recordings may be analyzed and the information used for
research reports. I also understand that testing information and treatment progress as
recorded in the client file may be used for research purposes. I further understand that
when such usages are made of this information or recordings, that the names of the
patients treated will be concealed.
I agree and understand that Baylor may freely use these tapes and files for purposes of
education and research.
I further agree and understand that by signing this Consent Agreement, these
recordings and files become the property of the Center and I hereby relinquish any and
all claims to benefits, financial or otherwise which I had, now have, or may have in the
future or which my heirs, executors, administrators, or assigns may have or claim to
have from the use of these recordings.
BY: _________________________________________________________________________
(Date)
Baylor University Speech and Hearing Clinic
Consent and Acknowledgement of Receipt of Privacy Notice
I understand that as part of the provision of speech language/hearing services, Baylor University
Speech and Hearing Clinic, hereinafter referred to as the Center, creates and maintains health
records and other information describing among other things, my health history, symptoms,
examination and test results, diagnoses, treatment, and any plans for future care or treatment.
I have been provided with a Notice of Privacy Practices that provides a more complete
description of the uses and disclosures of certain health information. I understand that I have
the right to review the notice prior to signing this consent. I understand that the Center reserves
the right to change the Notice, and will provide you with a copy of any revised notice at the time
of your next visit. I understand that I have the right to request restrictions as to how my health
information may be used or disclosed to carry out treatment, payment, or healthcare operations
(quality assessment and improvement activities, underwriting, premium rating, conducting or
arranging for medical review, legal services, and auditing functions, etc.) and that the
organization is not required to agree to the restrictions requested.
By signing this form, I consent to the use and disclosure of protected health information about
me for the purposes of treatment, payment and health care operations. I have the right to
revoke this consent, in writing, except where disclosures have already been made in reliance on
my prior consent.
This consent is given freely with the understanding that:
1. Any and all record, whether written or oral or in electronic format, are confidential
and cannot be disclosed for reasons outside of treatment, payment or health care
operations without my prior written authorization, except as otherwise provided by
law.
2. A photocopy or fax of this consent is as valid as this original.
3. I have the right to request that the use of my Protected Health Information, which is
used or disclosed for the purposes of treatment, payment or health care operations
as restricted. I also understand that the Center and I must agree to any restriction in
writing that I request on the use and disclosure of my Protected Health Information;
and agree to terminate any restrictions in writing on the use and disclosure of my
Protected Health Information which have been previously agreed upon.
_________________________________________
_________________________________________
PATIENT’S SIGNATURE (OR GUARDIAN, IF A MINOR)
DATE
_________________________________________
_________________________________________
NAME PRINTED
WITNESS (optional)
Baylor University Speech and Hearing Clinic
NOTICE OF PRIVACY PRACTICES (NON-STUDENTS)
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please view it carefully.
If you have any questions about this Notice please contact our Privacy Officer, Mr. Warren Ricks, at (254) 710-8333.
This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment
or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control
your protected health information. “Protected Health Information” is information about you, including demographic information, that may
identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of the Notice of Privacy Practices. We may change the terms of our notice at any time. The new
notice will be effective for all protected health information that we maintain at that time.
Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website at
http://www3baylor.edu/communication_disorders/privacy_notice.pdf, calling the Baylor University Speech and Hearing Clinic, hereinafter
referred to as the Center, and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next visit.
1.
Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
You will be asked to sign a consent form. Once you have consented to use and disclosure of your protected health information for
treatment, payment and health care operations by signing the consent form, your protected health information will be used or disclosed as
described in this Section 1. Your protected health information may be used by the Center and others outside of our clinic that are involved
in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used
and disclosed to pay your health care bills and to support the operation of the Center.
Following are examples of the types of uses and disclosures of your protected health care information that the Center is permitted to make
once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures
that may be made by the Center once you have provided consent.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your speech language/hearing
services and any related services. This includes the coordination or management with a third party that has already obtained your
permission to have access to your protected health information. For example, we would disclose protected health information to physicians
who may be treating you when we have the necessary permission from you to disclose your protected health information. For example,
your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the
necessary information to diagnose or treat you.
In addition, we may disclose your protected speech language/hearing services information from time-to-time to another health care
provider (e.g., a physician, specialist or laboratory) who becomes involved in your care by providing assistance with your health care
diagnosis or treatment.
Payment: Your protected health information may be used, as needed, to obtain payment for your speech language/hearing services.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities
of the Center. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, marketing
and conducting or arranging for other business activities.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or
other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information
for other marketing activities. We may also send you information about products or services that we believe may be beneficial to you .You
may contact our Privacy Contact to request that these materials not be sent to you.
Uses and Disclosures of Protected Health Information Based upon your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise
permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that the
Center has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object
We may 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. If you are not present or able to agree or object to the use or
disclosure of the protected health information, your doctor 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 be disclosed.
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 heath 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 your protected health information to an authorized public or private entity to
assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, the Center
shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment.
Communication Barriers: We may use or disclose your protected health information if your doctor attempts to obtain consent from you
but is unable to do so due to substantial communication barriers and the doctor, using professional judgment, that you intend to consent
to use or disclose under the circumstances.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your protected health information in the following situations without your consent or authorization. These
situations include:
Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law.
The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be
notified, as required by law, of any such uses or disclosures.
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. The disclosure will be made for the purpose of controlling disease, injury or
disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government
agency that is collaborating with the public health authority.
Health Oversight: We may disclose protected health information to health oversight agency for activities authorized by law, such as
audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health
care system, government benefit programs, other government regulatory programs and civil rights laws.
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.
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.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, 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 request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law
enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information
requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of
criminal conduct, (5) in the event that a crime occurs on the premises of the Department of Communication Sciences and Disorders and (6)
medical emergency (not on the Center’s premises) and it is likely that a crime has occurred.
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.
Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation
laws and other similar legally established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and the Center created
or received your protected health information in the course of providing care to you.
Required Uses and Disclosures: Under the law, we must make disclosures to 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 Sections 164.500 et. Seq.
2.
Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise
these rights.
You have the 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 a designated record set for as long as we can maintain the protected health information.
A “designated record set” contains speech language/hearing services records and any other records that the Center uses for making
decisions about you.
Under federal law, however, you may not inspect or copy the following records: information compiled in reasonable anticipation of, or use
in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to
protected health information. Depending on the circumstances, a decision to deny access may be reviewed. In some circumstances, you
may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical
record.
You have the right to request a restriction of your protected health information. This means you may ask us 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. Your request must state the specific restriction requested and to
whom you want the restriction to apply.
The Center is not required to agree to a restriction that you may request. If the Center believes it is in your best interest to permit use and
disclosure of your protected health information, your protected health information will not be restricted. If the center does agree to the
requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to
provide emergency treatment. You may request a restriction by contacting our Privacy Officer.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment
will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the
basis for the request. Please make this request in writing to our Privacy Officer.
You may have the right to have the Baylor University Speech and Hearing Clinic amend your protected health information.
This means you may request an amendment of protected health information about you in a designated record set for as long as we
maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you
have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a
copy of any such rebuttal. Please contact our Privacy Officer to determine if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy
Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification
purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request
a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically
3.
Complaints
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 Contact of your complaint. We will not retaliate against you for filing a complaint.
You may contact our Privacy Officer, Mr. Warren Ricks, at (254) 710-8333, for further information about the complaint process.
This notice is effective on April 14, 2003.-