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Notice of
Privacy 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.
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
person listed below.
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 physicians in this practice are
specialists. When we provide treatment, we may
request that your primary care physician share
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
Portability and Accountability Act (HIPAA).
Those regulations create several privileges that
patients may exercise. We will 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 or mail 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:
Sleep Consultants, Inc.
Attn: Carla Peveto
1521 Cooper Street
Fort Worth, TX 76104
This notice is
effective on the following date: April 14th,
2003.
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.
Texas Pulmonary
& Critical Care Consultants, P.A.
Sleep
Consultants, Inc.
Acknowledgement
of Review of
Notice of
Privacy Practices
I have reviewed this
office’s Notice of Privacy Practices, which
explains how my medical information will be used
and disclosed. I understand that I am entitled
to receive a copy of this document.
________________________________________________
Signature of Patient or Personal
Representative
_______________________________
Date
_________________________________________
Name of Patient or Personal Representative
_________________________________________
Description of Personal Representative’s
Authority
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