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(Specialty Physician)
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.
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. We may change
our policies and this notice at any time and have those
revised policies apply to all the protected health information
we maintain. If or when we change our notice, we will post
the new notice in the office where it can be seen. You
can request a paper copy of this notice, or any revised
notice, at any time (even if you have allowed us to communicate
with you electronically). For more information about this
notice or our privacy practices and policies, please contact
the person listed at the end of this document.
A. 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 we provide
to you. For example, we may complete a claim form to
obtain payment from your insurer or HMO. That form will
contain medical information, such as a description of
the medical services 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 service 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. We may ask another physician
to review this practice’s charts and medical records
to evaluate our performance so that we may ensure that
this practice provides only the best health care.
B. Disclosures That Can Be Made Without Your Authorization
There are situations in which we are permitted 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 that rely
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.
Because Texas law requires physicians to report child
abuse or neglect, we may disclose medical information to
a public agency authorized to receive reports of child
abuse or neglect. Texas law also requires a person having
cause to believe that an elderly or disabled person is
in a state of abuse, neglect, or exploitation to report
the information to the state, and HIPAA privacy regulations
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:
§ The information is released pursuant to legal process,
such as a warrant or subpoena;
§
The information pertains to a victim of crime and you are
incapacitated;
§
The information pertains to a person who has died under
circumstances that may be related to criminal conduct;
§
The information is about a victim of crime and we are unable
to obtain the person’s agreement;
§
The information is released because of a crime that has
occurred on these premises; or
§
The information is released to locate a fugitive, missing
person, or suspect.
We also may 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
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 person or a cause
of death. Further, we may release your medical information
to a funeral director when such a disclosure is necessary
for the director to carry out his duties.
Required by Law
We may release your medical information when the disclosure
is required by law.
C. Your Rights Under Federal Law
The U. S. Department of Health and Human Services created
regulations intended to protect patient privacy as required
by the Health Insurance Portability and Accountability
Act (HIPAA). Those regulations create several privileges
that patients may exercise. We will not retaliate against
patients who exercise 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 health care 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.
You also may request that we limit disclosure to family
members, other relatives, or close personal friends who
may or may not be involved in your care.
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 at the end of this document.
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 at the end of this document.
We may ask that a narrative of that information be provided
rather than copies. However, if you do not agree to our
request, we will provide copies.
We can refuse to provide some of the information you ask
to inspect or ask to be copied for the following reasons:
§ The information is psychotherapy notes.
§
The information reveals the identity of a person who provided
information under a promise of confidentiality.
§
The information is subject to the Clinical Laboratory Improvements
Amendments of 1988.
§
The information 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 arrange for a review
of our decision on your request. Any such review will be
made by another licensed health care provider who was not
involved in the prior decision to deny access.
Texas law requires us to be ready to provide copies or
a narrative within 15 days of your request. We will inform
you 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.
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 at the end of this
document. We will respond within 60 days of your request.
We may refuse to allow an amendment for the following
reasons:
§ The information wasn’t created by this practice
or the physicians in this practice.
§
The information is not part of the designated record set.
§
The information is not available for inspection because
of an appropriate denial.
§
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
now have the incorrect information.
Accounting of Certain Disclosures
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
at the end of this document. 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.
D. Appointment Reminders, Treatment Alternatives,
and Other Benefits
We may contact you by (telephone, mail, and/or email)
to provide appointment reminders, information about treatment
alternatives, or other health-related benefits and services
that may be of interest to you.
E. 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 U. S. Department
of Health and Human Services. We will not retaliate against
you for filing a complaint with us or the government. 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
F. 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.
G. 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:
Mariela Acevedo
1740 W. 27th St., Suite 234
Houston, TX 77008
713-802-9779
713-802-2289
mariela@mnwent.com
This notice is effective 04-11-03
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