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
Health information which we receive and/or create about you,
personally, in this office, relating to your past, present, or
future health, treatment, or payment for health care services, is
"protected health information" under the Federal law known as the
Health Insurance Portability and Accountability Act (HIPAA). Your
health information is further protected by any pertinent state
law that is more protective or stringent than HIPAA. This Notice
describes how we protect personal health information (otherwise
referred to as "protected health information") we have about you,
and how we may use and disclose this information. This Notice
also describes your rights with respect to protected health
information and how you can exercise those rights.
I may use or disclose PHI without your consent or
authorization in the following circumstances:
1. Child Abuse: If I have
cause to believe that a child has been, or may be, abused,
neglected, or sexually abused, I must make a report of such
within 48 hours to the Texas Department of Protective and
Regulatory Services, the Texas Youth Commission, or to any local
or state law enforcement agency.
2. Adult and Domestic Abuse:
If I have cause to believe that an elderly or disabled person is
in a state of abuse, neglect, or exploitation, I must immediately
report such to the Department of Protective and Regulatory
Services.
3. Health Oversight: If a
complaint is filed against me with the Texas State Board of
Licensed Professional Counselors, they have the authority to
subpoena confidential mental health information from me relevant
to that complaint.
4. Judicial or Administrative
Proceedings: If you are involved in a court proceeding and a
request is made for information about your diagnosis and
treatment and the records thereof, such information is privileged
under state law, and I will not release information, without
written authorization from you or your personal or legally
appointed representative, or a court order. The privilege does
not apply when you are being evaluated for a third party or where
the evaluation is court ordered. You will be informed in advance
if this is the case.
5. Serious Threat to Health or
Safety: If I determine that there is a probability of
imminent physical
injury by you to yourself or others, or there is a probability of
immediate mental or emotional injury to you, I may disclose
relevant confidential mental health information to medical or law
enforcement personnel.
6. Worker's Compensation: If
you file a worker's compensation claim, I may disclose records
relating to your diagnosis and treatment to your employer's
insurance carrier
Uses and disclosures that may be made of your health
information:
Treatment: Protected health information received or
created by your health care providers in this office will be
recorded in your medical record and used while you are engaged in
treatment. The sharing of your protected health information may
progress to other health care providers outside of this office
who are involved in your care, such as referring providers,
specialty or consulting physicians, lab technicians, or other
providers involved in the provision, coordination, or management
of your health care.
Payment: Your protected health information will be used
and disclosed to obtain payment for treatment and services you
receive. A bill may be sent to you, an insurance company, or a
third-party payer with accompanying documentation that identifies
you, your diagnosis, procedures performed, and supplies used, and
any other information that may be reasonably required for payment
purposes. Your protected health information may also be used or
disclosed in other payment related activities, such as claims
management activities. We may tell your insurance company about a
test or treatment you are going to receive to receive prior
approval or to determine whether your insurance plan will cover
the test or treatment.
Health Care Operations: Your protected health information
will be used for the purpose health care operations. Healthcare
operations include quality assessment and improvement activities,
reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performance,
conducting training programs, accreditation, certification,
licensing or credentialing activities, as well as business
planning, development and management activities, customer
services and business restructuring, acquisition, consolidation
or merger. These uses, and disclosures are necessary to run this
office and make sure that all our patients receive quality
care. For example, the medical staff in this office may use
your health information to assess the care you received, and the
outcome of your case compared to others like it. Your information
may be reviewed for risk management or quality improvement
purposes in our efforts to continually improve the quality and
effectiveness of the care and services we provide.
Appointment Reminders: This office reserves the right to
contact you, as permitted by law, with appointment reminders or
information about treatment alternatives and other health related
benefits that may be appropriate to you.
Business Associates: Some or all your protected health
information may be subject to disclosure through contracts for
services with business associates outside of this office to
assist this office in providing health care. Examples of business
associates include billing companies, data processing companies,
or companies that provide administrative or specialty services.
To protect your health information, we require these Business
Associates to follow the same standards held by this office
through terms detailed in a written agreement.
Facility Directory: Unless you object, this facility will
use your name, room number, general condition, and religious
affiliation for directory purposes. This information will be made
available to clergy, and, except for religious affiliation, this
information will also be disclosed to others who ask for you by
name.
Individuals Involved in Your Care or Payment of Your Care:
Unless you object or we infer from the circumstances based on our
professional judgment that you would likely not object, we may
provide protected health information about your condition and/or
recovery to a family member, close personal friend, or any other
person identified by you who is involved in your medical care. We
may also give information to someone who helps pay for your care.
Your protected health information may be used or disclosed to
notify or assist in notifying family members, personal
representatives, or other persons responsible for your care about
your well being or your whereabouts. We may also disclose
protected health information to public or private agencies
authorized by law to engage in disaster relief efforts to carry
out their responsibilities in specific disaster situations.
To Avert a Serious Threat to Health or Safety: This office
may disclose protected health information about you when such
disclosure is necessary to prevent or lessen a serious and
imminent threat to the health or safety of a person or the
public. Any disclosure, however, would only be made to someone
who is reasonably able to help prevent the threat.
For Health Oversight Activities: This office may disclose
protected health information to health oversight agencies for
oversight activities authorized by law, such as audits, civil,
administrative or criminal investigations or proceedings,
inspections, and licensure or disciplinary actions. For example,
we may disclose protected health information to any governmental
agency or regulator with whom you may file a complaint or as part
of the regulatory agency's investigation or audit.
For Judicial & Administrative Proceedings: If you or your
estate is involved in a claim or lawsuit, this office may
disclose protected health information about you in response to a
court or administrative order. We may also disclose protected
health information about you in response to a subpoena, discovery
request, or other lawful process by someone else involved in the
dispute, so long as it is demonstrated that efforts have been
made to tell you about the request or to obtain an order
protecting the protected health information requested.
For Law Enforcement Purposes: This office may disclose
protected health information in response to a request by a law
enforcement official made through a court order, subpoena,
warrant, summons or similar process. We may also disclose limited
protected health information about you as otherwise permitted by
law in crime related circumstances, such as in identifying or
locating a suspect, fugitive, material witness or missing person,
or when necessary to report a crime in a medical emergency or
about criminal conduct in our office.
For Public Health Activities: This office may disclose
protected health information about you to public health
authorities that are authorized by law to collect information
for:
Maintaining vital records, such as births and deaths;
Reporting child abuse or neglect;
Preventing or controlling disease, injury, or disability;
Notifying a person regarding potential exposure to a communicable
disease;
Notifying a person regarding the potential risk for spreading or
contracting a disease or condition;
Reporting reactions to drugs or problems with products or
devices; or,
Notifying individuals if a product or device they may be using
has been recalled.
As Required by Law: This office will disclose protected
health information required and/or otherwise authorized by
Federal, state or local law. This includes, for example,
disclosure to comply with reporting requirements by certain
professionals of suspected abuse and neglect.
Concerning Victims of Abuse, Neglect, or Domestic
Violence: This office may notify the appropriate government
authority if we believe a patient has been the victim of abuse,
neglect, or domestic violence. We will only make this disclosure
if you agree, or when required or authorized by law.
Research: Under certain circumstances, this office may use
and disclose your protected health information for research
purposes. For example, a research project may involve comparing
the health and recovery of all patients who received one test or
treatment to those who received another, for the same
condition. All research projects, however, must be approved
by an Institutional Review Board, or other privacy review board
as permitted within the regulations, that has reviewed the
research proposal and established protocols to ensure the privacy
of your protected health information. In certain instances, we
may also disclose your protected health information to
researchers preparing to conduct a research project, for example,
to help them look for patients with specific medical needs, so
long as the medical information they review does not leave our
offices and they provide certain assurances.
Funeral Directors and Coroners or Medical Examiners: Your
health information may be disclosed consistent with laws
governing mortician services. We may release your protected
health information to a coroner or medical examiner to assist in
identifying a deceased individual or to determine cause of death.
Worker's Compensation: This office will release
information to the extent authorized by law in matters of
worker's compensation.
Organ Procurement Organizations: If you are an organ
donor, this office may release your protected health information
to organizations that handle organ procurement or organ, eye or
tissue transplantation or to an organ donation bank, as necessary
to facilitate organ or tissue donation and transplantation.
For Specialized Government Functions: This office may
disclose protected health information about you to Federal
officials for the conduct of lawful intelligence,
counterintelligence, and other national security activities
authorized by law.
Correctional Facilities: This office will release medical
information on incarcerated individuals to correctional agents or
institutions for the necessary welfare of the individual or for
the health and safety of other individuals. The rights outlined
in this Notice of Privacy Practices will not be extended to
incarcerated individuals.
Fundraising Efforts: This office reserves the right to
contact you as part of our fundraising efforts.
Other Uses and Disclosure of Protected Health Information:
Other uses and disclosures of protected health information not
covered by this Notice will be made only with your written
authorization or that of your legal representative. If you or
your legal representative authorize us to use or disclose
protected health information about you, you or your legal
representative may revoke that authorization, in writing, at any
time, except to the extent that we have already acted relying on
the authorization. To revoke a prior authorization, you must
submit your revocation in writing to directly to this office.
Your rights regarding protected health information we maintain
about you:
Right to Inspect and Copy: In most cases, you have the
right to inspect and obtain a copy of the protected health
information that we maintain about you. To inspect and copy your
protected health information, you must submit your request in
writing to this office. To receive a copy of your protected
health information, you may be charged a fee for the
photocopying, mailing, or other costs associated with your
request. In some very limited circumstances we may, as authorized
by law, deny your request to inspect and obtain a copy of your
protected health information. You will be notified of a denial to
any part or parts of your request. Some denials, by law,
are reviewable, and you will be notified regarding the procedures
for invoking a right to have a denial reviewed. Other denials,
however, as set forth in the law, are not reviewable. Each
request will be reviewed individually, and a response will be
provided to you in accordance with the law.
Right to Amend Your Protected Health Information: If you
believe that your protected health information is incorrect or
that an important part of it is missing, you have the right to
ask us to amend your protected health information while it is
kept by or for us. You must provide your request and your reason
for the request in writing and submit it to this office.
We may deny your request if it is not in writing or does not
include a reason that supports the request. In addition, we may
deny your request if you ask us to amend protected health
information that we believe:
Is accurate and complete;
Was not created by us, unless the person or entity that created
the protected health information is no longer available to make
the amendment;
Is not part of the protected health information kept by or for
us; or
Is not part of the protected health information which you would
be permitted to inspect and copy.
If your right to amend is denied, we will notify you of the
denial and provide you with instructions on how you may exercise
your right to submit a written statement disagreeing with the
denial and/or how you may request that your request to amend and
a copy of the denial be kept together with the protected health
information at issue, and disclosed together with any further
disclosures of the protected health information at issue.
Right to an Accounting of Disclosures: You have the right
to request an accounting or list of the disclosures that we have
made of protected health information about you. This list will
not include certain disclosures as set forth in the HIPAA
regulations, including those made for treatment, payment, or
health care operations, or for purposes of national security, or
made pursuant to your authorization or made directly to you. To
request this list, you must submit your request in writing to
this office. Your request must state the time period from which
you want to receive a list of disclosures. The time may not be
longer than six years and may not include dates before April 14,
2003. Your request should indicate in what form you want the list
(for example, on paper or electronically). The first list you
request within a 12-month period will be free. We may charge you
for responding to any additional requests. We will notify you of
the cost involved and you may choose to withdraw or modify your
request at that time before any costs are incurred.
Right to Request Restrictions: You have the right to
request a restriction or limitation on protected health
information we use or disclose about you for treatment, payment
or health care operations, or that we disclose to someone who may
be involved in your care or payment for your care, like a family
member or friend, or for notification purposes as described in
this Notice. While we will consider your request, we are not
required to agree to it. If we do agree to it, we will comply
with your request, except in emergency situations where your
protected health information is needed to provide you with
emergency treatment. We will not agree to restrictions on uses or
disclosures that are legally required, or those which are legally
permitted and which we reasonably believe to be in the best
interest of your health.
Right to Request Confidential Communications: You have the
right to request that we communicate with you about protected
health information in a certain manner or at a certain location.
For example, you can ask that we only contact you at work or by
mail. To request confidential communications, you must make your
request in writing to this office and specify how or where you
wish to be contacted. We will accommodate all reasonable
requests.
Right to File a Complaint: If you believe your privacy
rights have been violated, you may file a complaint with this
office or with the Secretary of the Department of Health and
Human Services. To file a complaint with this office, please
contact:
Tracey Johnson, Human Resource Manager
10730 Potranco Road, Suite 122-242
San Antonio, TX 78251
Phone: 210-627-1629
Email: tjohnson@tajmanagement.us
You will not be penalized or otherwise retaliated against for
filing a complaint. If you have questions as to how to file a
complaint, please the Human Resource Manager listed above.
Our responsibilities:
This office is required to:
Maintain the privacy of your protected health information;
Provide you with this notice of our legal duties and privacy
practices with respect to your protected
health information;
and,
Abide by the terms of this Notice while it is in effect.
This office reserves the right to change the terms of this Notice
at any time and to make a new Notice with provisions effective
for all protected health information that we maintain. If
changes are made, this office will post changes on our web site.
To receive additional information:
For further explanation of this Notice you may contact:
Tracey Johnson, Human Resource Manager
10730 Potranco Road, Suite 122-242
San Antonio, TX 78251
Phone: 210-627-1629
Email: tjohnson@tajmanagement.us
Availability of Notice of Privacy Practices:
This notice will be posted where registration occurs. You have a
right to receive a copy of this notice, and all individuals
receiving care will be given a hard copy. "This notice will
be maintained and available for downloading at the following Web
site address: www.tajmanagement.us"
Acknowledgement:
I hereby acknowledge that I received a copy of this Notice of
Privacy Practices.
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