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.
USE AND DISCLOSURE OF HEALTH INFORMATION
Texas Family Medicine may use your information, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Texas Family Medicine has established policies to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
To Provide Treatment. Texas Family Medicine may use your health information to coordinate care within Texas Family Medicine and with others involved in your care, such as other health care professionals who have agreed to assist Texas Family Medicine in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. Texas Family Medicine also may disclose your health care information to individuals outside of Texas Family Medicine involved in your care including family members, pharmacists, suppliers of medical equipment or other health care professionals.
To Obtain Payment. Texas Family Medicine may include your health information in invoices to collect payment from third parties for the care you receive from Texas Family Medicine. For example, Texas Family Medicine may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Texas Family Medicine. Texas Family Medicine also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for the services that will be provided to you.
To Conduct Health Care Operations. Texas Family Medicine may use and disclose health information for its own operations in order to facilitate the function of Texas Family Medicine as necessary to provide quality care to all of Texas Family Medicine’s patients. Health care operations includes such activities as:
- Quality assessment and improvement activities.
- Activities designed to improve health or reduce health care costs.
- Protocol development, case management and care coordination.
- Contact health care providers and patients with information about treatment alternatives and other related functions that do not include treatment.
- Professional review and performance evaluation.
- Training programs including those in which students, trainees or practitioners in health care learn under supervision.
- Training of non-health care professionals.
- Accreditation, certification, licensing or credentialing activities.
- Review and auditing, including compliance reviews, medical review, legal services and compliance programs.
- Business planning and development including cost management and planning related analyses and formulary development.
- Business management and general administrative activities of Texas Family Medicine.
- Fundraising for the benefit of Texas Family Medicine.
For example, Texas Family Medicine may use your health information to evaluate its staff performance, combine your health information with other Texas Family Medicine patients in evaluating how to serve more effectively all Texas Family Medicine patients, disclose your health information to Texas Family Medicine staff and contracted personnel for training purposes, use your health information to contact you as a reminder regarding a visit to you, or contact you as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted).
For Fundraising Activities. Texas Family Medicine may use information about you including your name, address, phone number and the dates you received care in order to contact you to raise money for Texas Family Medicine. Texas Family Medicine may also release this information to a related Texas Family Medicine foundation. If you do not want Texas Family Medicine to contact you, notify our Compliance Officer that you do not wish to be contacted. You have the right to opt out of receiving fundraising communications.
For Appointment Reminders.Texas Family Medicine may use and disclose your health information to contact you as a reminder that you have an appointment for a home visit.
For Treatment Alternatives. Texas Family Medicine may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY ALSO BE USED AND DISCLOSED.
When Legally Required.Texas Family Medicine will disclose your health information when it is required to do so by any federal, state or local law.
When There Are Risks to Public Health.Texas Family Medicine may disclose your health information for public activities and purposes in order to:
- Prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions.
- Report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.
- Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
- Notify an employer about an individual who is a member of the workforce as legally required.
To Report Abuse, Neglect or Domestic Violence.Texas Family Medicine is allowed to notify government authorities if Texas Family Medicine believes a patient is the victim of abuse, neglect or domestic violence. Texas Family Medicine will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.
To Conduct Health Oversight Activities.Texas Family Medicine may disclose your health information to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Texas Family Medicine, however, may not disclose your health information if you are the subject of an investigation not directly related to your receipt of health care or public benefits.
In Connection with Judicial and Administrative Proceedings.Texas Family Medicine may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when Texas Family Medicine makes reasonable efforts either to notify you about the request or to obtain an order protecting your health information.
For Law Enforcement Purposes.As permitted or required by state law, Texas Family Medicine may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:
- As required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant subpoena or summons or similar process.
- For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
- Under certain limited circumstances, when you are the victim of a crime.
- To a law enforcement official if Texas Family Medicine has a suspicion that your death was the result of criminal conduct including criminal conduct at Texas Family Medicine.
- In an emergency in order to report a crime.
To Coroners and Medical Examiners. Texas Family Medicine may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.
To Funeral Directors.Texas Family Medicine may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, Texas Family Medicine may disclose your health information prior to and in reasonable anticipation of your death.
For Organ, Eye or Tissue Donation.Texas Family Medicine may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of facilitating the donation and transplantation.
For Research Purposes.Texas Family Medicine may, under very select circumstances, use your health information for research. Before Texas Family Medicine discloses any of your health information for such research purposes, the project will be subject to an extensive approval process.
In the Event of a Serious Threat to Health or Safety.Texas Family Medicine may, consistent with applicable law and ethical standards of conduct, disclose your health information if Texas Family Medicine, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
For Specified Government Functions. In certain circumstances, the federal regulations authorize Texas Family Medicine to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.
For Worker’s Compensation.Texas Family Medicine may release your health information for worker’s compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Most uses and disclosures of psycho-therapy notes and of PHI for marketing purposes and the sale of PHI require your authorization. Uses and disclosures not described in this Notice of Privacy Practices will be made only with your authorization. If you or you representative authorizes Texas Family Medicine to use or disclose your health information, you may revoke that authorization in writing at any time.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that Texas Family Medicine maintains:
- Right to request restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Texas Family Medicine’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, Texas Family Medicine is not required to agree to your request. If you wish to make a request for restrictions, please contact the Compliance Officer.
- Right to receive communications. You have the right to request that Texas Family Medicine communicate with you in a certain way. For example, you may ask that Texas Family Medicine only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact the Compliance Officer. Texas Family Medicine will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
- Right to inspect and copy your health information. You have the right to inspect and copy your health information including billing records. A request to inspect and copy records containing your health information may be made to the Compliance Officer. If you request a copy of your health information, Texas Family Medicine may charge a reasonable fee for copying and assembling costs associated with your request. You have the right to receive a copy of your electronic medical record in electronic form.
- Right to amend health care information. You or your representative have the right to request that Texas Family Medicine amend your records, if you believe that your health information is incorrect or incomplete. That request may be made as long as the information is maintained by Texas Family Medicine. A request for an amendment of records must be made in writing to the Compliance Officer. Texas Family Medicine may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by Texas Family Medicine, if the records you are requesting are not part of Texas Family Medicine’s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Texas Family Medicine, the records containing your health information are accurate and complete.
- Right to an accounting. You or your representative have the right to request an accounting of disclosures of your health information made by Texas Family Medicine for certain reasons, including reasons related to public purposes authorized by law and certain research. The request for an accounting must be made in writing to the Compliance Officer. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. Texas Family Medicine would provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
- Right to a paper copy of this notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact the Compliance Officer.
- Right to be notified of breach. Affected individuals have the right to be notified following a breach of unsecured protected health information.
- Right to restrict disclosure to health plan if paying out-of-pocket. You have the right to request (and Texas Family Medicine is required to agree) to restrict disclosure of protected health information to a health plan where the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out-of-pocket in full.
DUTIES OF THE AGENCY
Texas Family Medicine is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. Texas Family Medicine is required to abide by the terms of this Notice of its duties and privacy practices, as is and as it may be amended from time to time. Texas Family Medicine reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If Texas Family Medicine changes its Notice, Texas Family Medicine will provide a copy of the revised Notice to you or your appointed representative. You or your personal representative have the right to express complaints to Texas Family Medicine and to the Secretary of the U.S. Department of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to Texas Family Medicine should be made in writing to the Compliance Officer. Texas Family Medicine encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
Texas Family Medicine has designated Dr. Brian Byrd as its contact person for all issues regarding patient privacy and your rights under the federal privacy standards. Dr. Brian Byrd can be reached at Texas Family Medicine, 6100 Harris Parkway, Suite 250, Ft. Worth, TX 76132, 817-433-5155, email@example.com.
This Notice is effective April 15, 2013.