Privacy Policy

This notice describes how medical information about you may be used and disclosed and how

you can get access to that information.

PLEASE REVIEW THIS NOTICE CAREFULLY

This practice is committed to maintaining the privacy of your protected health information (PHI),

which includes information about your health condition, care and treatment you receive from the

Practice. The creation of a record detailing the care and services you receive helps this office to

provide you with quality health care. This notice details how your PHI may be used and

disclosed to third parties. This notice also details your rights regarding your PHI. The privacy of

PHI in patient files will be protected when the files are taken to and from the practice by placing

the files in a box or briefcase and kept within the custody of a doctor or employee of the practice

authorized to remove the files from the practice’s office. It may be necessary to take patient files

to a facility where a patient is confined or to a patient’s home where the patient if to be examined

or treated.

NO CONSENT REQUIRED –

(a) Treatment – In order to provide you with the health care you require, the Practice will

provide your PHI to those health care professionals, whether on the Practice’s staff or not, who

are directly involved in your care so they may understand your health condition and needs. For

example, a physician treating you for a condition or disease may need to know the results of your

most recent physical examination performed by this office.

(b) Payment – In order to receive payment for services provided to you, the Practice will

provide your PHI—directly or through a billing service—to appropriate third-party payers, in

accordance with their billing and payment requirements. For example, the Practice may need to

provide the Medicare program with information about health care services you received from the

Practice so that the Practice can be properly reimbursed. The Practice may also need to inform

your insurance plan about the treatment you are scheduled to receive so that it can determine

whether or not it will cover the treatment expenses.

(c) Health Care Operations – In order for the Practice to operate in accordance with applicable

laws and insurance requirements, and to continue providing quality and efficient care, it may be

necessary for the Practice to use and/or disclose your PHI. For example, the Practice may use

your PHI to evaluate the performance of its personnel in providing care to you.

The Practice may use and/or disclose your PHI without a written consent from you in the

following additional instances:

(a) De-identified Information – Information that does not identify you and, even without your

name, cannot be used to identify you.(b) Business Associate – To a business associate, provided the Practice obtains satisfactory

written assurance, in accordance with applicable law, that the business associate will

appropriately safeguard your PHI. A business associate is an entity that assists the Practice in

performing essential functions, such as a billing company that helps submit claims for

payment to insurance companies or other payers.

(c) Personal Representative – To a person who, under applicable law, has the authority to

represent you in making decisions related to your health care.

(d) Emergency Situations – for the purpose of obtaining or rendering emergency treatment to

you provided that the Practice attempts to obtain your Consent as soon as possible; or to a

public or private entity authorized by law or by its charter to assist in disaster relief efforts,

for the purpose of coordinating your care with such entities in an emergency situation.

(e) Communication Barriers – If, due to substantial communication barriers or an inability to

communicate, the Practice has been unable to obtain your consent, and the Practice determines—

using professional judgment—that your consent to receive treatment is clearly inferred from the

circumstances, it may proceed accordingly.

Public Health Activities – Such activities include, for example, information collected by a

public health authority, as authorized by law, to prevent or control disease. This information does

not identify you and, even without your name, cannot be used to identify you.

(g) Abuse, Neglect, or Domestic Violence – The Practice may disclose your PHI to a

government authority if required by law. If authorized by law, the Practice may also make such a

disclosure if it believes the disclosure is necessary to prevent serious harm.

(h) Health Oversight Activities – These are required by law and involve government agencies.

Such activities may include, for example, criminal investigations, disciplinary actions, or general

oversight related to the community’s health care system.

(i) Judicial and Administrative Proceedings – For example, the Practice may be required to

disclose your PHI in response to a court order or a lawfully issued subpoena.

(j) Law Enforcement Purposes – In certain instances, your PHI may need to be disclosed to a

law enforcement official. For example, your PHI may be the subject of a grand jury subpoena.

Additionally, the Practice may disclose your PHI if it believes your death was the result of

criminal conduct.

(k) Coroner or Medical Examiner – The Practice may disclose your PHI to a coroner or

medical examiner for the purposes of identifying you or determining your cause of death.

(l) Organ, Eye, or Tissue Donation – If you are an organ donor, the Practice may disclose your

PHI to the entity to whom you have agreed to donate your organs.

(m) Research – If the Practice is involved in research activities, your PHI may be used.

However, such use is subject to numerous governmental requirements intended to protect yourprivacy. Any information used will not identify you and cannot be used to identify you, even

without your name.

(n) Averting a Threat to Health or Safety – The Practice may disclose your PHI if it believes

the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or

safety of a person or the public. Such disclosure will be made only to an individual who is

reasonably able to prevent or lessen the threat.

Workers’ Compensation – If you are involved in a Workers’ Compensation claim, the Practice

may be required to disclose your PHI to an individual or entity that is part of the Workers’

Compensation system.

APPOINTMENT REMINDER – The Practice may, from time to time, contact you to provide

appointment reminders or information about treatment alternatives or other health-related

benefits and services that may be of interest to you. The following appointment reminders may

be used:

• (a) A postcard mailed to the address you provided

• (b) A telephone call to your home, with a message left on your answering machine or

with the individual who answers the phone.

• (c) A text message to the cell phone number provided

SIGN-IN LOG – The Practice maintains a sign-in log for individuals seeking care and treatment

in the office. The sign-in log is located in a position where staff can readily see who is seeking

care in the office, as well as the individual’s location within the Practice’s office suite. This

information may be seen by, and is accessible to, others who are seeking care or services in the

Practice’s offices.

FAMILY/FRIENDS – The Practice may disclose your PHI to your family member, other

relative, close personal friend, or any other person identified by you, when the PHI is directly

relevant to that person’s involvement with your care or payment for your care. The Practice may

also use or disclose your PHI to notify or assist in notifying (including identifying location) a

family member, personal representative, or another person responsible for your care about your

location, general condition, or death. However, in both cases, the following conditions will

apply:

(a) If you are present at or prior to the use or disclosure of your PHI, the Practice may use or

disclose your PHI if you agree, or if the Practice can reasonably infer from the circumstances—

based on the exercise of its professional judgment—that you do not object to the use or

disclosure.

(b) If you are not present, the Practice will, in the exercise of professional judgment, determine

whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is

directly relevant to the person’s involvement in your care.AUTHORIZATION – Uses and/or disclosures, other than those described above, will be made

only with your written authorization.

YOUR RIGHTS – You have the right to:

(a) Revoke any Authorization and/or Consent, in writing, at any time. To request a revocation,

you must submit a written request to the Practice’s Compliance Officer.

(b) Request restrictions on certain uses and/or disclosures of your PHI as provided by law.

However, the Practice is not obligated to agree to any requested restrictions. To request

restrictions, you must submit a written request to the Compliance Officer. Your request must

specify what information you want to limit, whether you want to limit the Practice’s use or

disclosure or both, and to whom the limits should apply. If the Practice agrees to your request, it

will comply unless the information is needed for emergency treatment.

(c) Receive confidential communications or PHI by alternative means or at alternative locations

by submitting a written request to the Compliance Officer. The Practice will accommodate all

reasonable requests.

(d) Inspect and obtain a copy of your PHI as provided by law. You must submit a written request

to the Compliance Officer. The Practice may charge you a fee for the cost of copying, mailing, or

other supplies associated with your request.

(e) Amend your PHI as provided by law. To request an amendment, submit a written request with

a reason supporting the amendment to the Compliance Officer. The Practice may deny your

request if it is not in writing, lacks supporting reasons, involves PHI not created by the Practice,

or if the information is accurate and complete.

PRACTICE REQUIREMENTS – (a) The Practice is required by federal law to maintain the

privacy of your PHI (Protected Health Information) and to provide you with this Privacy Notice

detailing the Practice’s legal duties and privacy practices with respect to your PHI.

(b) The Practice is required by state law to maintain a higher level of confidentiality with respect

to certain portions of your medical information that is provided for under federal law. In

particular, the Practice is required to comply with the following state statutes: Section 381.004

relating to HIV testing, Chapter 384 relating to sexually transmitted diseases, and Section

456.057 relating to patient records ownership, control, and disclosure.

(c) The Practice is required to abide by the terms of this Privacy Notice.

(d) The Practice reserves the right to change the terms of this Privacy Notice and to make the

new Privacy Notice provisions effective for all of your PHI that it maintains.

(e) The Practice will distribute any revised Privacy Notice to you prior to implementation.

Effective Date: This Notice is in effect as of 08/25/2015