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. Personal identifiable information about your health, health care, and payment for health care is called Protected Health Information. We must safeguard your Protected Health Information and give you this Notice about our privacy practices that explains how, when and why we may use or disclose your Protected Health Information. Except in the situations set out in the Notice, we must use or disclose only the minimum necessary Protected Health Information to carry out the use or disclosure. We must follow the practices described in this Notice, but we can change our privacy practices and the terms of this Notice at any time. If we revise the Notice, you may receive an updated version of the Notice of Privacy Practices on your next visit. You also may obtain a copy by visiting the patient portal.
Uses and Disclosures of Your Protected Health Information That Do Not Require Your Consent
• For treatment purposes. We may disclose your health information to doctors, nurses and others who provide your health care.
• To obtain payment. We may disclose your health information to collect payment for your health care (i.e. insurance company, health savings; for prior authorizations or continued payment).
• For health care operations. We may contact you to remind you of your appointment or to call you by name in the waiting room when it is time for your visit.
• When required by law. We may be required to disclose your Protected Health Information to law enforcement officers, courts or government agencies.
• For activities related to death. We may be required to disclose your health information to coroners, medical examiners and funeral directors.
• To avert a threat to health or safety. To avoid a serious threat to health or safety, we may disclose health information to law enforcement officers or persons who might prevent or lessen that threat.
• For workers’ compensation purposes. We may disclose your health information to government authorities under workers’ compensation laws.
Uses and Disclosures of Protected Health Information That Offer You an Opportunity to Object
• To your family, friends or others involved in your care. We may share with these people information related to their involvement in your care or information to notify them as to your location or general condition. We may release your health information to organizations handling disaster relief efforts.
Uses and Disclosures of Your Protected Health Information That Require Your Consent
• For research purposes. In order to serve our patient community, we may want to use your health information in research studies.
• For any other purposes not described in this Notice. Without your permission, we will not use or disclose your health information under any circumstances that are not described in this Notice.
Your Rights Regarding Your Protected Health Information
• To inspect and request a copy of your Protected Health Information. You may look at and obtain a copy of your Protected Health Information in most cases. If we use or maintain the requested information electronically, you may request that information in electronic format. A fee will be applied to any paper records requested ($1.00 per page).
• To request that we correct your Protected Health Information. If you think that there is a mistake or a gap in our file of your health information, you may ask us in writing to correct the file.
• To request a restriction on the use or disclosure of your Protected Health Information.
To obtain a paper copy of this Notice. Upon your request, we will give you a paper copy of this Notice.
How to Complain about Our Privacy Practices
If you think we may have violated your privacy rights, or if you disagree with a decision we made about your Protected Health Information, you u may also file a complaint with the Office of the Ombudsman
P. O. Box 13247
Austin, TX 78711-3247
Phone: 877-787-8999
We will take no action against you if you make a complaint to either or both of these persons. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. This signature is only acknowledgement that you have received this notice of our Privacy Practices.