Notice of Privacy Policies and Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
EFFECTIVE APRIL 14, 2003
This Notice of Privacy Policies and Practices (the “Notice”) tells you about the ways we may use and disclose medical information about you and your rights and our obligations regarding the use and disclosure of your medical information. This Notice applies to [Insert provider name], including its employees (the “Practice”).
I. OUR OBLIGATIONS.
We are required by law to:
- Make sure that the medical information we have about you is kept private, to the extent required by state and federal law;
- Give you this Notice explaining our legal duties and privacy practices with respect to medical information about you; and
- Follow the terms of the version of this Notice that is currently in effect at the time we acquire medical information about you.
II. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe the different reasons that we typically use and disclose medical information. These categories are intended to be generic descriptions only, and not a list of every instance in which we may use or disclose medical information. Please understand that for these categories, the law generally does not require us to get your consent in order for us to release your medical information.
A. For Treatment. We may use medical information about you to provide you with medical treatment and services, and we may disclose medical information about you to doctors, nurses, technicians, medical students, or hospital personnel who are providing or involved in providing medical care to you. For example, physicians and nursing staff will have access to your medical record in order to provide treatment to you.
B. For Payment. We may use and disclose medical information about you so that we may bill and collect from you, an insurance company, or a third party for the services we provide. This may also include the disclosure of medical information to obtain prior authorization for treatment and procedures from your insurance plan. For example, we may send a claim for payment to your insurance company, and that claim may have a code on it that describes the services that have been rendered to you.
C. For Health Care Operations. We may use and disclose medical information about you for our health care operations. These uses and disclosures are necessary to operate our practice appropriately and make sure all of our patients receive quality care. For example, we may need to use or disclose your medical information in order to conduct certain cost-management practices, or to provide information to our insurance carriers.
D. Quality Assurance. We may need to use or disclose your medical information for our internal processes to determine that we are providing appropriate care to our patients.
E. Utilization Review. We may need to use or disclose your medical information to perform a review of the services we provide to ensure that the proper level of services are received by our patients, depending on their condition and diagnosis.
F. Peer Review. We may need to use or disclose medical information about you in order for us to review the credentials and actions of our health care personnel to ensure they meet our qualifications and standards.
G. Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that we believe may be of interest to you.
H. Appointment Reminders and Health Related Benefits and Services. We may contact you (including contacting you by phone and leaving a message on an answering machine) to provide appointment reminders and other information. We may use and disclose medical information to tell you about health-related benefits or services that we believe may be of interest to you.
I. Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care, as well as to someone who helps pay for your care, but we will do so only as allowed by state or federal law, or in accordance with your prior authorization.
J. As Required by Law. We will disclose medical information about you when required to do so by federal, state, or local law.
K. To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent or decrease a serious and imminent threat to your health or safety or the health and safety of the public or another person. Such disclosure would only be to someone able to help prevent the threat, or to appropriate law enforcement officials.
L. Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.
M. Research. We may use or disclose your medical information to an Institutional Review Board or other authorized research body if your consent has been obtained as required by law, or if the information we provide them is “de-identified”.
N. Military and Veterans. If you are or were a member of the armed forces, we may release medical information about you as required by the appropriate military authorities.
O. Worker's Compensation. We may release medical information about you for your employer’s worker's compensation or similar program. These programs provide benefits for work-related injuries. For example, if you have injuries that resulted from your employment, worker’s compensation insurance or a state worker’s compensation program may be responsible for payment for your care, in which case we might be required to provide information to the insurer or program.
P. Public Health Risks. We may disclose medical information about you to public health authorities for public health activities. As a general rule, we are required by law to disclose the certain types of information to public health authorities, such as the Texas Department of Health. The types of information generally include information used:
- To prevent or control disease, injury, or disability (including the reporting of a particular disease or injury).
- To report births and deaths.
- To report suspected child abuse or neglect.
- To report reactions to medications or problems with medical devices and supplies.
- To notify people of recalls of products they may be using.
- To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
- To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
- To provide information about certain medical devices.
- To assist in public health investigations, surveillance, or interventions.
Q. Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include audits, civil, administrative, or criminal investigations and proceedings, inspections, licensure and disciplinary actions, and other activities necessary for the government to monitor the health care system, certain governmental benefit programs, certain entities subject to government regulations which relate to health information, and compliance with civil rights laws.
R. Legal Matters. If you are involved in a lawsuit or a legal dispute, we may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process. In addition to lawsuits, there may be other legal proceedings for which we may be required or authorized to use or disclose your medical information, such as investigations of health care providers, competency hearings on individuals, or claims over the payment of fees for medical services.
S. Law Enforcement. We may disclose your medical information if we are asked to do so by law enforcement officials, or if we are required by law to do so. Examples of these situations are:
- In response to a court order, subpoena, warrant, summons or similar process.
- To identify or locate a suspect, fugitive, material witness or missing person.
- When the information is about the victim of a crime.
- When the information is about a death we believe may be the result of criminal conduct.
- When the information is about criminal conduct in our office.
- In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
- To report certain types of wounds or physical injuries (for example, gunshot wounds).
T. Coroners, Medical Examiners and Funeral Home Directors. We may disclose your medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about our patients to funeral home directors as necessary to carry out their duties.
U. National Security and Intelligence Activities. We may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
V. Inmates. If you are an inmate of a correctional institution or under custody of a law enforcement official, we may disclose medical information about you to the correctional institution or the law enforcement official. This would be necessary for the institution to provide you with health care, to protect your health and safety and the health and safety of others, or for the safety and security of the correctional institution or law enforcement official.
W. Marketing of Related Health Services. We may use or disclose your protected health information to send you treatment or healthcare operations communications concerning treatment alternatives or other health-related products or services. We may provide such communications to you in instances where we receive financial remuneration from a third party in connection with such communications. You have the right to opt out of receiving any such compensated communications, and should inform us if you do not wish to receive them. Additionally, if we send such communications, the communications themselves note that we have received compensation for the communication, and will have clear and conspicuous instructions on how you may opt out of receiving such communications in the future.
X. Fundraising. We may use or disclose limited amounts of your protected health information to send you fundraising materials. Any such fundraising materials sent to you will have clear and conspicuous instructions on how you may opt out of receiving such communications in the future.
III. OTHER USES OF MEDICAL INFORMATION.
A. Authorizations. There are times we may need or want to use or disclose your medical information other than for the reasons listed above, but to do so we will need your prior permission. If you provide us permission to use or disclose medical information about you for such other purposes, you may revoke that permission in writing at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
B. Paid Disclosures. Other than expressly provided herein, any other disclosures of your protected health information will require your specific authorization. Most disclosures of protected health information for which we would receive compensation would require your authorization. Additionally, we would need your specific authorization for most disclosures of your protected health information to the extent it constitutes “psychotherapy notes” or is for marketing purposes.
IV. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
Federal and state laws provide you with certain rights regarding the medical information we have about you. The following are a summary of those rights.
A. Right to Inspect and Copy. Under most circumstances, you have the right to inspect and/or copy your medical information that we have in our possession, which generally includes your medical and billing records. To inspect or copy your medical information, you must submit your request to do so in writing to the Practice’s HIPAA Officer at the address listed in Section VI. below.
If you request a copy of your information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. The fee we may charge will be the amount allowed by state law.
In certain very limited circumstances allowed by law, we may deny your request to review or copy your medical information. We will give you any such denial in writing. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will abide by the outcome of the review.
B. Right to Amend. If you feel the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by the Practice. To request an amendment, your request must be in writing and submitted to the HIPAA Officer at the address listed in Section VI. below. In your request, you must provide a reason as to why you want this amendment. If we accept your request, we will notify you of that in writing.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that (i) was not created by us, (ii) is not part of the information kept by the Practice, (iii) is not part of the information which you would be permitted to inspect and copy, or (iv) is accurate and complete. If we deny your request, we will notify you of that denial in writing.
C. Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures" of your medical information. This is a list of the disclosures we have made for up to six years prior to the date of your request of your medical information, but does not include disclosures for Treatment, Payment, or Health Care Operations (as described in Sections II. A., B., and C. of this Notice) or disclosures made pursuant to your specific authorization (as described in Section III. of this Notice), or certain other disclosures. To request this list of accounting, you must submit your request in writing to the Practice’s HIPAA Officer at the address set forth in Section VI. below.
Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve-month period will be free. For additional lists, we may charge you a reasonable fee for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
D. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you in various situations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. In addition, there are certain situations where we won’t be able to agree to your request, such as when we are required by law to use or disclose your medical information. To request restrictions, you must make your request in writing to the Practice’s HIPAA Officer at the address listed in Section VI. below. In your request, you must specifically tell us what information you want to limit, whether you want us to limit our use, disclosure, or both, and to whom you want the limits to apply.
As stated above, in most instances we do not have to abide by your request for restrictions on disclosures that are otherwise allowed. However, in certain instances, if you make a request for restrictions on disclosures, we will be obligated to abide by them. Specifically, if you pay for an item or service in full, out of pocket, and request that we not disclose the information relating to that service to a health plan, we will be obligated to abide by that restriction. You should be aware that such restrictions may have unintended consequences, particularly if other providers need to know that information (such as a pharmacy filling a prescription). It will be your obligation to notify any such other providers of this restriction. Additionally, such a restriction may impact your health plan’s decision to pay for related care that you may not want to pay for out of pocket (and which would not be subject to the restriction).
E. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at home, not at work or, conversely, only at work and not at home. To request such confidential communications, you must make your request in writing to the Practice’s HIPAA Officer at the address listed in Section VI. below.
We will not ask the reason for your request, and we will use our best efforts to accommodate all reasonable requests, but there are some requests with which we will not be able comply. Your request must specify how and where you wish to be contacted.
F. Business Associates. There are some services provided in our organization through contracts with business associates. When these services are contracted, we may disclose your medical information to our business associate so that they can perform the job we have asked them to do. To protect your medical information, however, we require the business associate to appropriately safeguard your information.
G. Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this Notice, you must make your request in writing to the Practice’s HIPAA Officer at the address set forth in Section VI. below.
H. Breach Notification. .] In certain instances, we may be obligated to notify you (and potentially other parties) if we become aware that your protected health information has been improperly disclosed or otherwise subject to a “breach” as defined in HIPAA.
V. CHANGES TO THIS NOTICE.
We reserve the right to change this Notice at any time, along with our privacy policies and practices. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice, along with an announcement that changes have been made, as applicable, in our office. When changes have been made to the Notice, you may obtain a revised copy by sending a letter to the Practice’s HIPAA Officer at the address listed in Section VI. below or by asking the office receptionist for a current copy of the Notice.
If you believe that your privacy rights as described in this notice have been violated, you may file a complaint with the Practice at the following address or phone number:
Attn: HIPAA Officer
950 West Magnolia Ave., Fort Worth, Texas, 76104
To file a complaint, you may either call or send a written letter. The Practice will not retaliate against any individual who files a complaint. If you do not want to file a compliant with the Practice, you may file one with the Secretary of the Department of Health and Human Services.
In addition, if you have any questions about this Notice, please contact the Practice’s HIPAA Officer at the address or phone number listed above.