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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.
(copy available upon request)
This practice uses and discloses health information about you for
treatment, to obtain payment for treatment, for administrative purposes,
and to evaluate the quality of care that you receive.
This notice describes our privacy practices. You can request a
copy of this notice at any time. For more information about this
notice or our privacy practices and policies, please contact the
privacy officer.
Treatment, Payment, Health Care Operations
Treatment
We are permitted to use and disclose your medical information
to those involved in your treatment. For example, the physician
in this practice is a specialist. When we provide treatment, we
may request that your primary care physician share your medical
information with us. Also, we may provide your primary care physician
information about your particular condition so that he or she can
appropriately treat you for other medical conditions, if any.
Payment
We are permitted to use and disclose your medical information
to bill and collect payment for the services provide to you. For
example, we may complete a claim form to obtain payment from your
insurer or HMO. The form will contain medical information, such
as a description of the medical service provided to you, that your
insurer or HMO needs to approve payment to us.
Health Care Operations
We are permitted to use or disclose your medical information
for the purposes of health care operations, which are activities
that support this practice and ensure that quality care is delivered.
For example, we may engage the services of a professional to aid
this practice in its compliance programs. This person will review
billing and medical files to ensure we maintain our compliance with
regulations and the law.
Disclosures That Can Be Made Without Your Authorization
There are situations in which we are permitted by law to disclose
or use your medical information without your written authorization
or an opportunity to object. In other situations we will ask for
your written authorization before using or disclosing any identifiable
health information about you. If you choose to sign an authorization
to disclose information, you can later revoke that authorization,
in writing, to stop future uses and disclosures. However, any revocation
will not apply to disclosures or uses already made or taken in reliance
on that authorization.
Public Health, Abuse or Neglect, and Health Oversight
We may disclose your medical information for public health
activities. Public health activities are mandated by federal, state,
or local government for the collection of information about disease,
vital statistics (like births and death), or injury by a public
health authority. We may disclose medical information, if authorized
by law, to a person who may have been exposed to a disease or may
be at risk for contracting or spreading a disease or condition.
We may disclose your medical information to report reactions to
medications, problems with products, or to notify people of recalls
of products they may be using.
We may also disclose medical information to a public agency authorized
to receive reports of child abuse or neglect. Texas law requires
physicians to report child abuse or neglect. Regulations also permit
the disclosure of information to report abuse or neglect of elders
or the disabled.
We may disclose your medical information to a health oversight
agency for those activities authorized by law. Examples of these
activities are audits, investigations, licensure applications and
inspections which are all government activities undertaken to monitor
the health care delivery system and compliance with other laws,
such as civil rights laws.
Legal Proceedings and Law Enforcement
We may disclose your medical information in the course
of judicial or administrative proceedings in response to an order
of the court (or the administrative decision-maker) or other appropriate
legal process. Certain requirements must be met before the information
is disclosed.
If asked by a law enforcement official, we may disclose your medical
information under limited circumstances provided that the information:
- Is released pursuant to legal process, such as a warrant or
subpoena;
- Pertains to a victim of crime and your are incapacitated;
- Pertains to a person who has died under circumstances that
may be related to criminal conduct;
- Is about a victim of crime and we are unable to obtain the
person’s agreement;
- Is released because of a crime that has occurred on these premises;
or
- Is released to locate a fugitive, missing person, or suspect.
We may also release information if we believe the disclosure is
necessary to prevent or lessen an imminent threat to the health
or safety of a person.
Workers’ Compensation
We may disclose your medical information as required by
the Texas workers’ compensation law.
Inmates
If you are an inmate or under the custody of law enforcement, we
may release your medical information to the correctional institution
or law enforcement official. This release is permitted to allow
the institution to provide you with medical care, to protect your
health or the health and safety of others, or for the safety and
security of the institution.
Military, National Security and Intelligence Activities,
Protection of the President
We may disclose your medical information
for specialized governmental functions such as separation or
discharge from military service, requests as necessary by appropriate
military command officers (if you are in the military), authorized
national security and intelligence activities, as well as authorized
activities for the provision of protective services for the President
of the United States, other authorized government officials, or
foreign heads of state.
Research,Organ Donation, Coroners, Medical Examiners, and Funeral
Directors
When a research project and its privacy protections have been
approved by an Institutional Review Board or privacy board, we may
release medical information to researchers for research purposes.
We may release medical information to organ procurement organizations
for the purpose of facilitating organ, eye, or tissue donation if
you are a donor. Also, we may release your medical information to
a coroner or medical examiner to identify a deceased or a cause
of death. Further, we may release your medical information to a
funeral director where such a disclosure is necessary for the director
to carry out his duties.
Required by Law
We may release your medical information where the disclosure
is required by law.
Your Rights Under Federal Privacy Regulations
The United States Department of Health and Human Services created
regulations intended to protect patient privacy as required by the
Health Insurance Portab not retaliate against a patient that exercises
their HIPAA rights.
Requested Restrictions
You may request that we restrict or limit how your protected health
information is used or disclosed for treatment, payment, or healthcare
operations. We do NOT have to agree to this restriction, but if
we do agree, we will comply with your request except under emergency
circumstances.
To request a restriction, submit the following in writing: (a) The
information to be restricted, (b) what kind of restriction you are
requesting (i.e. on the use of information, disclosure of information
or both), and (c) to whom the limits apply. Please send the request
to the address and person listed below. You may also request
that we limit disclosure to family members, other relatives, or
close personal friends that may or may not be involved in your care.
Receiving Confidential Communications by Alternative Means
You may request that we send communications of protected
health information by alternative means or to an alternative location.
This request must be made in writing to the person listed below.
We are required to accommodate only reasonable requests.
Please specify in your correspondence exactly how you want us to
communicate with you and, if you are directing us to send it to
a particular place, the contact/address information.
Inspection and Copies of Protected Health Information
You may inspect and/or copy health information that is
within the designated record set, which is information that is used
to make decisions about your care. Texas law requires that requests
for copies be made in writing and we ask that requests for inspection
of your health information also be made in writing. Please send
your request to the person listed below.
We can refuse to provide some of the information you ask to inspect
or ask to be copied if the information:
- Includes psychotherapy notes.
- Includes the identity of a person who provided information
if it was obtained under a promise of confidentiality.
- Is subject to the Clinical Laboratory Improvements Amendments
of 1988.
- Has been compiled in anticipation of litigation.
We can refuse to provide access to or copies of some information
for other reasons, provided that we provide a review of our decision
on your request. Another licensed health care provider who was not
involved in the prior decision to deny access will make any such
review.
Texas law requires that we are ready to provide copies or a narrative
within 15 days of your request. We will inform you of when the records
are ready or if we believe access should be limited. If we deny
access, we will inform you in writing.
HIPAA permits us to charge a reasonable cost based fee. The Texas
State Board of Medical Examiners (TSBME) has set limits on fees
for copies of medical records that under some circumstances may
be lower than the charges permitted by HIPAA. In any event, the
lower of the fee permitted by HIPAA or the fee permitted
by the TSBME will be charged.
Amendment of Medical Information
You may request an amendment of your medical information
in the designated record set. Any such request must be made in writing
to the person listed below. We will respond within 60 days of your
request. We may refuse to allow an amendment if the information:
- Wasn’t created by this practice or the physicians here in this
practice.
- Is not part of the Designated Record Set?
- Is not available for inspection because of an appropriate denial.
- If the information is accurate and complete.
Even if we refuse to allow an amendment you are permitted to include
a patient statement about the information at issue in your medical
record. If we refuse to allow an amendment we will inform you in
writing. If we approve the amendment, we will inform you in writing,
allow the amendment to be made and tell others that we know have
the incorrect information.
Accounting of Certain Disclosures
The HIPAA privacy regulations permit you to request, and
us to provide, an accounting of disclosures that are other than
for treatment, payment, health care operations, or made via an authorization
signed by you or your representative. Please submit any request
for an accounting to the person listed below. Your first accounting
of disclosures (within a 12 month period) will be free. For additional
requests within that period we are permitted to charge for the cost
of providing the list. If there is a charge we will notify you and
you may choose to withdraw or modify your request before
any costs are incurred.
Appointment Reminders, Treatment Alternatives, and Other
Health-related Benefits
We may contact you by telephone, mail, or both to provide appointment
reminders, information about treatment alternatives, or other health-related
benefits and services that may be of interest to you.
Complaints
If you are concerned that your privacy rights have been violated,
you may contact the person listed below. You may also send a written
complaint to the United States Department of Health and Human Services.
We will not retaliate against you for filing a complaint with the
government or us. The contact information for the United States
Department of Health and Human Services is:
U.S. Department of Health and Human Services
HIPAA Complaint
7500 Security Blvd., C5-24-04
Baltimore, MD 21244
Our Promise to You
We are required by law and regulation to protect the privacy of
your medical information, to provide you with this notice of our
privacy practices with respect to protected health information,
and to abide by the terms of the notice of privacy practices in
effect.
Questions and Contact Person for Requests
If you have any questions or want to make a request pursuant to
the rights described above, please contact:
Nadia Dubas - Office Manager/Privacy Officer
6550 Fannin, Suite 2201
Houston, TX 77030
(713) 797-9498
This notice is effective on the following date: April 14, 2003.
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