Victoria Womens ClinicNotice of Privacy PracticesAs required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.PLEASE REVIEW IT CAREFULLY.
A. OUR COMMITMENT TO YOUR PRIVACY.Our practice is dedicated to maintaining the privacy of your medical information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We need these records to provide you with quality care and to comply with certain legal requirements. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your medical information. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time. We realize that these laws are complicated, but we must provide you with the following important information:
· How we may use and disclose your medical information;
· Your privacy rights in your medical information; and
· Our obligations concerning the use and disclosure of your medical information.
B. CHANGES TO THIS NOTICE.The terms of this notice apply to all records containing your medical information that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
C. WHO WILL FOLLOW THIS NOTICE.This Notice describes our privacy practices, as well as the privacy practices of: (a) any health care professional authorized to enter information into your chart; (b) all departments, sections, and units of our facility; (c) any member of a volunteer group we allow to help you while you are in our facility; (d) all employees, staff and other personnel. All of these entities, sites and locations follow the terms of this Notice. In addition, these entities, sites and locations may share medical information with each other for the treatment, payment and health care operations activities described in this Notice.
D. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
E. HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION.The following categories describe the different ways in which we may use and disclose your medical information. For each category of uses or disclosures we will explain what we mean and give you some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the below categories.Privacy Officer
605 E. San Antonio, #310E
Victoria, Texas 77901
(361) 578-5233
1. Treatment. Our practice may use your medical information to provide you with medical treatment or services. We may disclose medical information about you to doctors or other Clinic personnel who are involved in taking care of you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your medical information in order to write a prescription for you, or we might disclose your medical information to a pharmacy when we order a prescription for you. Many of the people who work for our practice, including, but not limited to, our doctors and nurses, may use or disclose your medical information in order to treat you or to assist others in your treatment. Finally, we may disclose your medical information to other health care providers for purposes related to your treatment, such as physicians who will provide follow up care or physical therapy organizations.
2. Payment. Our practice may use and disclose your medical information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover or pay for your treatment. We also may use and disclose your medical information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your medical information to bill you directly for services and items. We may disclose your medical information to other health care providers and entities to assist in their billing and collection efforts.
3. Health Care Operations. Our practice may use and disclose your medical information to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your medical information to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your medical information to other health care providers and entities to assist in their health care operations.
4. To Business Associates For Treatment, Payment, and Health Care Operations. Our practice may disclose medical information about you to one of our business associates in order to carry out treatment, payment, or health care operations. For example, we may disclose medical information about you to a company who bills insurance companies on our behalf to enable that company to help us obtain payment for the health care services we provide.
5. Appointment Reminders. Our practice may use and disclose your medical information to contact you and remind you of an appointment.
6. Treatment Alternatives. Our practice may use and disclose your medical information to inform you of potential treatment options or alternatives.
7. Health-Related Benefits and Services. Our practice may use and disclose your medical information to inform you of health-related benefits or services that may be of interest to you.
8.Individuals Involved in Your Care or Payment for Your Care. Our practice may release medical information about you to a family member, other relative, or close personal friend who is involved in your medical care if the medical information released is directly relevant to such person’s involvement with your care. We also may release information to someone who helps pay for your care. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.
9. Disclosures Required By Law. Our practice will use and disclose your medical information about you when required to do so by federal, state, or local law.
Public Health Risks. Our practice may disclose your medical information to public health authorities that are authorized by law to collect information for the purpose of:1. Maintaining vital records, such as births and deaths.
2. Reporting child abuse or neglect;
3. Preventing or controlling disease, injury or disability
4. Notifying an individual who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition;
5. Reporting reactions to medications or problems with products or devices;
6. Notifying individuals of recalls or products or devices they may be using;
7. Notifying the appropriate government authority regarding the potential abuse or neglect of an adult patient (including domestic violence). We will only make this disclosure if the patient agrees or we are required or authorized by law to disclose this information.
8. Notifying your employer under certain limited circumstances related primarily to workplace injury or illness or medical surveillance.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose your medical information in response to a court or administrative order, if you are involved in a lawsuit or similar proceedings. We may also disclose your medical information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
· Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement;
· Concerning a death we believe has resulted from criminal conduct;
· Regarding criminal conduct at our offices;
· In response to a court order, subpoena, warrant, summons or similar legal process;
· To identify or locate a suspect, fugitive, material witness, or missing person, but only if limited information (e.g., name and address, date and place of birth, social security number, blood type and RH factor, type of injury, date and time of treatment, and date and time of death, if applicable) is disclosed; or
· In an emergency, to report a crime, including the location of the crime or victims, the identity, and or location of the person who committed the crime.
5. Deceased Patients. Our practice may release medical information to a medical examiner or Coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information in order for funeral directors to perform their jobs.
6. Organ and Tissue Donation. Our practice may release your medical information to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
7. Research. Under certain circumstances, our practice may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This special approval process requires an evaluation of the proposed research project and its use of medical information, and balances these research needs with our patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project generally will have been approved through this special approval process. However, this special approval process is not required when we allow medical information about you to be reviewed by people who are preparing a research project and who want to look at information about patients with specific medical needs, so long as the medical information these people review does not leave the premises.
8. Serious Threats to Health or Safety. Our practice may use and disclose medical information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
9. Armed Forces and Foreign Military Personnel. If you are a member of the Armed Forces, our practice may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
10. National Security and Intelligence Activities. Our practice may disclose your medical information to federal officials for intelligence and national security activities authorized by law. We may also disclose your medical information to federal officials in order to protect the President, otherOfficials, or foreign heads of state, or to conduct investigations.
11. Inmates. Our practice may disclose your medical information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you; (b) for the safety and security of the institution; and/or (c) to protect your health and safety or the health and safety of other individuals.
12. Workers’ Compensation. Our practice may release your medical information for workers’ compensation or similar programs. G. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION. You have the following rights regarding medical information that we maintain about you:
1. Confidential Communications. You have the right to request that our practicecommunicate with you about your medical matters in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to our Privacy Officer, (361) 578-5233, specifying the requested method of contact or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your medical information for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your medical information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your medical information, you must make your request in writing to our Privacy Officer, (361) 578-5233. Your request must describe in a clear and concise fashion:
· The information you wish restricted;
· Whether you are requesting to limit our practice’s use, disclosure, or both; and
· To whom you want the limits to apply.
3. Inspections and Copies. You have the right to inspect and obtain a copy of themedical information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to our Privacy Officer, (361) 578-5233 in order to inspect and/or obtain a copy of your medical information. Our practice may charge you a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews. The person conducting the review will not be the person who denied your request.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to our Privacy Officer, (361) 578-5233. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the medical information kept by or for the practice; (c) not part of the health information which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your medical information for non-treatment or operations purposes. Use of your medical information as part of the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to our Privacy Officer, (361) 578-5233. All requests for an “accounting of disclosures” must state a timely period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a paper copy of this notice, contact our Privacy Officer, (361) 578-5233.
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Again, if you have any questions regarding this Notice or our health information
privacy policies, please contact our Privacy Officer, (361) 578-5233.
Victoria Womens Clinic
RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGMENT FORM.
I, ________________________________________, have received a copy of Victoria Womens Clinic Notice of Privacy Practices.
______________________________ __________________________
Signature of Patient Date
Patient has refused to sign Notice of Privacy Practices Acknowledgment Form.
______________________________ ___________________________
Signature of Witness Date
Victoria Women's Clinic
Medical Drive, Suite 100, Victoria, Texas 77904 • Telephone: (361) 578-5233 · Fax: (361) 573-5803
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