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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT
TO US.
Our Legal Duty
We are required by
applicable federal and state laws to maintain the privacy of your protected
health information. We are also required to give you this notice about our
privacy practices, our legal duties, and your rights concerning your
protected health information. We must follow the privacy practices that are
described in this notice while it is in effect. This notice takes effect
April 14, 2003, and will remain in effect until we replace it.
We
reserve the right to change our privacy practices and the terms of this
notice at any time, provided that such changes are permitted by applicable
law. We reserve the right to make the changes in our privacy practices and
the new terms of our notice effective for all protected healthin formation
that we maintain, including medical information we created or received
before we made the changes.
You may request a copy of our notice
(or any subsequent revised notice) at any time. For more information about
our privacy practices, or for additional copies of this notice, please
contact us using the information listed at the end of this notice.
Uses and Disclosures of Protected Health Information
We will use and disclose your protected health information about you
for treatment, payment, and health care operations. Following are examples
of the types of uses and disclosures of your protected health care
information that may occur. These examples are not meant to be exhaustive,
but to describe the types of uses and disclosures that maybe made by our
office.
Treatment: We will use and disclose your protected health
information to provide, coordinate or manage your healthcare and any related
services. This includes the coordination or management of your health care
with a third party. For example, we would disclose your protected health
information, as necessary, to a home health agency that provides care to
you. We will also disclose protected health information to other physicians
who may be treating you. 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 health information from time to
time to another physician or health care provider (e.g., a specialist or
laboratory)who, at the request of your physician, becomes involved in your
care by providing assistance with your health care diagnosis or treatment to
your physician.
Payment: Your protected health information will
be used, as needed, to obtain payment for your health care services. This
may include certain activities that your health insurance plan may undertake
before it approves or pays for the health care services we recommend for
you, such as: making a determination of eligibility or coverage for
insurance benefits, reviewing services provided to you for protected health
necessity, and undertaking utilization review activities. For example,
obtaining approval for a hospital stay may require that your relevant
protected health information be disclosed to the health plan to obtain
approval for the hospital admission.
Health Care Operations: We
may use or disclose, as needed, your protected health information in order
to conduct certain business and operational activities. These activities
include, but are not limited to, quality assessment activities, employee
review activities, training of students, licensing, and conducting or
arranging for other business activities.
For example, we may use
a sign-in sheet at the registration desk where you will be asked to sign
your name. We may also call you by name in the waiting room when your doctor
is ready to see you. We may use or disclose your protected health
information, as necessary, to contact you by telephone or mail to remind you
of your appointment.
We will share your protected health
information with third party "business associates" that perform various
activities (e.g., billing, transcription services) for the practice.
Whenever an arrangement between our office and a business associate involves
the use or disclosure of your protected health information, we will have a
written contract that contains terms that will protect the privacy of your
protected health information.
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. For example, your name
and address may be used to send you a newsletter about our practice and the
services we offer. We may also send you information about products or
services that we believe may be beneficial to you. You may contact us to
request that these materials not be sent to you.
Uses and
Disclosures Based On Your Written Authorization:Other uses and disclosures
of your protected health information will be made only with your
authorization,unless otherwise permitted or required by law as described
below.
You may give us written authorization to use your
protected health information or to disclose it to anyone for any purpose. If
you give us an authorization, you may revoke it in writing at any time. Your
revocation will not affect any use or disclosures permitted by your
authorization while it was in effect. Without your written authorization, we
will not disclose your health care information except as described in this
notice.
Others Involved in Your Health Care: 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 health 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 protected health
information to notify or assist in notifying a family member, personal
representative or any other person that is responsible for your care of your
location, general condition or death.
Marketing: We may use your
protected health information to contact you with information about treatment
alternatives that may be of interest to you. We may disclose your protected
health information to a business associate to assist us in these activities.
Unless the information is provided to you by a general newsletter or in
person or is for products or services of nominal value, you may opt out of
receiving further such information by telling us using the contact
information listed at the end of this notice.
Research; Death;
Organ Donation: We may use or disclose your protected health information for
research purposes in limited circumstances. We may disclose the protected
health information of a deceased person to a coroner, protected health
examiner, funeral director or organ procurement organization for certain
purposes.
Public Health and Safety: We may disclose your
protected health information to the extent necessary to avert a serious and
imminent threat to your health or safety, or the health or safety of others.
We may disclose your protected health information to a government agency
authorized to oversee the health care system or government programs or its
contractors, and to public health authorities for public health purposes.
Health
Oversight: We may disclose protected health information to a 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; to track products; to enable product recalls;
to make repairs or replacements; or to conduct post marketing surveillance,
as required.
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.
Required
by Law: We may use or disclose your protected health information when we are
required to do so by law. For example, we must disclose your protected
health information to the U.S. Department of Health and Human Services upon
request for purposes of determining whether we are in compliance with
federal privacy laws. We may disclose your protected health information when
authorized by workers' compensation or similar laws.
Process and
Proceedings: We may disclose your protected health information in response
to a court or administrative order, subpoena, discovery request or other
lawful process,under certain circumstances. Under limited circumstances,such
as a court order, warrant or grand jury subpoena, wemay disclose your
protected health information to law enforcement officials.
Law
Enforcement: We may disclose limited information to a law enforcement
official concerning the protected health information of a suspect, fugitive,
material witness, crime victim or missing person. We may disclose the
protected health information of an inmate or other person in lawful custody
to a law enforcement official or correctional institution under certain
circumstances. We may disclose protected health information where necessary
to assist law enforcement officials to capture an individual who has
admitted to participation in a crime or has escaped from lawful custody.
Patient Rights
Access: You have the right to look at or get copies of your protected
health information, with limited exceptions. You must make a request in
writing to the contact person listed herein to obtain access to your
protected health information. You may also request access by sending us a
letter to the address at the end of this notice. If you request copies, we
will charge you $25.00 for each page or$10.00 per hour to locate and copy
your protected health information, and postage if you want the copies mailed
to you. If you prefer, we will prepare a summary or an explanation of your
protected health information for a fee. Contact us using the information
listed at the end of this notice for a full explanation of our fee
structure.
Accounting of Disclosures: You have the right to
receive a list of instances in which we or our business associates disclosed
your protected health information for purposes other than treatment,
payment, health care operations and certain other activities after April 14,
2003. After April14, 2009, the accounting will be provided for the past
six(6) years. We will provide you with the date on which we made the
disclosure, the name of the person or entity to whom we disclosed your
protected health information, a description of the protected health
information we disclosed, the reason for the disclosure, and certain other
information. If you request this list more than once in a12-month period, we
may charge you a reasonable, cost-based fee for responding to these
additional requests. Contact us using the information listed at the end of
this notice for a full explanation of our fee structure.
Restriction
Requests: You have the right to request that we place additional
restrictions on our use or disclosure of your protected health information.
We are not required to agree to these additional restrictions, but if we do,
wewill abide by our agreement (except in an emergency). Any agreement we may
make to a request for additional restrictions must be in writing signed by a
person authorized to make such an agreement on our behalf. We will not be
bound unless our agreement is so memorialized in writing.
Confidential
Communication: You have the right to request that we communicate with you in
confidence about your protected health information by alternative means or
to an alternative location. You must make your request in writing. We must
accommodate your request if it is reasonable, specifies the alternative
means or location,and continues to permit us to bill and collect payment
from you.
Amendment: You have the right to request that we amend
your protected health information. Your request must be in writing, and it
must explain why the information should be amended. We may deny your request
if we did not create the information you want amended or for certain other
reasons. If we deny your request, we will provide you a written explanation.
You may respond with a statement of disagreement to be appended to the
information you wanted amended. If we accept your request to amend the
information, we will make reasonable efforts to inform others, including
people or entities you name, of the amendment and to include the changes in
any future disclosures of that information.
Electronic Notice: If
you receive this notice on our website or by electronic mail (e-mail), you
are entitled to receive this notice in written form. Please contact us using
the information listed at the end of this notice to obtain this notice in
written form.
Questions and Complaints
If
you want more information about our privacy practices or have questions or
concerns, please contact us using the information below. If you believe that
we may have violated your privacy rights, or you disagree with a decision we
made about access to your protected health information or in response to a
request you made, you may complain to us using the contact information
below. You also may submit a written complaint to the U.S. Department of
Health and Human Services. We will provide you with the address to file your
complaint with the U.S. Department of Health and Human Services upon
request.
We support your right to protect the privacy of your
protected health information. We will not retaliate in anyway if you choose
to file a complaint with us or with the U.S. Department of Health and Human
Services
Name of Contact Person: Larry
Roberts, MD, MA
Telephone: (806) 510-3376
Address: 2005 N. 2nd
Ave., Ste. D
Canyon, TX
79015