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CAPITAL MEDICAL CLINIC, LLP
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, your care may require the involvement
of a specialist. When we refer you to a specialist, we will share some
or all of your medical information with that physician to facilitate
the delivery of care. OR
the physician in
this practice is a specialist. When we provide treatment, we may request
that your primary care physician share your medical 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. OR
For example, we
may ask another physician to review this practice’s charts and
medical records to evaluate our performance so that we may ensure that
only the best health care is provided by this practice.
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, mail, or fax 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:
Debbie Cleveland,
Privacy Officer
1301 West 38th Street, Suite 601 Austin, TX 78705
(512) 454-5171 or by fax (512) 454-0704
This notice is effective on the following date: APRIL 14, 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.
CAPITAL MEDICAL
CLINIC, LLP
Acknowledgement
of Review of
Notice of Privacy Practices
I have been given the opportunity to review 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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