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APPENDIX A
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR
CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION.
USES AND DISCLOSURES
Treatment: Your child’s health information may be used by staff members or disclosed
to other health care professionals for the purpose of evaluating your child’s health,
diagnosing medical conditions, and providing treatment. For example, results of
diagnostic tests and procedures will be available in your child’s IEP to all health
professionals who may provide treatment or who may be consulted by staff members.
Payment/Reimbursement: Your child’s health information may be used to seek
payment/reimbursement from Medicaid under the School Health and Related Services
(SHARS) program. For example: Medicaid will receive information on dates of service,
the services provided, and the medical condition being treated.
INDIVIDUAL RIGHTS
You have certain rights under the federal privacy standards. These include:
The right to request restrictions on the use and disclosure of your protected health
information.
The right to inspect and copy the protected health information.
The right to amend or submit corrections to your protected health information.
The right to receive an accounting of how and to whom the protected health
information has been disclosed.
The right to receive a printed copy of this notice.
Contact Person:
If you would like to inspect or copy the protected health information, make a comment or
complaint, or for further information contact:
Title:
DIRECTOR OF SPECIAL EDUCATION
Name:
BECKY NIX
Address:
P.O. Box 95
City, State, Zip:
Gail, TX 79738
Telephone Number:
806-756-4313
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