NOTICE OF PRIVACY PRACTICES
This notice describes how health information about you may
be used and disclosed and how you can get access to this information.
Please review it carefully.
We understand that medical information about you and your health is personal.
We are committed to protecting medical information about you. Our practice
is dedicated, and applicable federal and state laws require us, to maintain
the privacy of your health information. These laws also require us to
provide you with this Notice of our privacy practices, and to inform to
you of your rights, and our obligations, concerning your health information.
We are required to follow the privacy practices described below while
this Notice is in effect. This Notice is effective as of 4/14/03 and will
remain in effect until we replace it.
CHANGES TO NOTICE:
We reserve the right to change this Notice and the privacy practices described
below at any time in accordance with applicable law. Prior to making significant
changes to our privacy practices, we will alter this Notice to reflect
the changes, and make the revised Notice available to you on request.
Any changes we make to our privacy practices and/or this Notice may be
applicable to health information created or received by us prior to the
date of changes. You may request a copy of our Notice at any time. For
more information about our privacy practices, or for additional copies
of this Notice, please contact us using the information listed at the
end of this Notice.
A. PERMITTED USES AND DISCLOSURES OF HEALTH INFORMATION
1. You should be aware that during the course of our relationship
with you we will likely use and disclose health information about
you for treatment, payment, and healthcare operations. Examples of
these activities are as follows:
- Treatment: We may use or disclose your health information to a
physician or other healthcare provider providing treatment to you.
- Payment: We may use and disclose your health information to obtain
payment for services we provide to you.
- Healthcare Operations: We may use and disclose you health information
in connection with our healthcare operations. Healthcare operations
include quality assessment and improvement activities, reviewing the
competence or qualifications of healthcare professionals, evaluating
provider performance, and other business operations.
2. You should be aware that our practice does not require obtaining,
or confirming the existence of authorization prior to:
a) Emergency treatment;
b) Treatment, when such treatment is required by law; or
c) Treatment of patients when communication barrier prevent obtaining
Consent.
You should also be aware that you have the right to revoke that
Consent at any time by providing the practice with written notice.
B. AUTHORIZATIONS: You may specifically authorize
us to use your health information for any purpose or to disclose your
health information to anyone, by submitting such an authorization in
writing. Upon receiving an authorization from you in writing, we may
use or disclose your health information in accordance with that authorization.
You may revoke an authorization at any time by notifying us in writing.
Your revocation will not affect any use or disclosures permitted by
your authorization while it was in effect. Unless you give us a written
authorization, we cannot use or disclose your health information for
any reason except those permitted by this Notice.
C. DISCLOSURES TO FAMILY AND PERSONAL REPRESENTATIVES: We
must disclose your health information to you, as described in the Patient
Rights section of this Notice. Such disclosures will be made to any
of your personal representatives appropriately authorized to have access
and control of your health information. We may disclose your health
information to a family member, friend or other person to the extent
necessary to help with your healthcare or with payment for your healthcare
only if authorized to do so. In the event of you incapacity or in emergency
circumstances, we will disclose health information based on a determination
using our professional judgment disclosing only health information that
is directly relevant to the person’s involvement in your healthcare.
D. MARKETING: We will not use your health information
for marketing communications without your written authorization.
E. USES OR DISCLOSURES REQUIRED BY LAW: We will disclose
medical information about you when required to do so by federal, state
or local law.
F. PATIENT AND THIRD PARTY PROTECTION: Only as permitted
by law, we may disclose your health information to the extent necessary
to avert a serious threat to your health or safety or the health or
safety of others.
G. LAW ENFORCEMENT/NATIONAL SECURITY: We may release
medical information if asked to do so by a law enforcement official
or in response to a court order, subpoena, warrant, summons or similar
process. If you are a member of the armed forces, we 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.
H. APPOINTMENT REMINDERS/FOLLOWUP: We may use or disclose
your health information to provide you with appointment reminders (such
as voicemail, postcards, or letters).
PATIENT RIGHTS:
A. ACCESS TO RECORDS: You have the right to inspect
and copy your medical and billing records. To inspect and/or to receive
a copy your medical records, you must submit your request in writing
to Texas Breast Care, Las Colinas Medical Center, Plaza One, 6750 N. MacArthur Blvd., Suite 205, Irving, TX 75039, or in person with proof of a valid identification.
B. ACCOUNTING OF CERTAIN DICLOSURES: Upon written
request, you have the right to receive a list of instances in which
we or our business associates disclosed your health information for
purposes other than treatment, payment, healthcare operations and other
activities authorized by you, for the last 6 years, but not before April
14, 2003. The first list you request within a 12-month period will be
free. For additional lists, we may charge you a reasonable, cost-based
fee. 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.
C. RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You
have the right to request a restriction or limitation on the medical
information we use or disclose about you for treatment, payment or health
care operations. You also have the right to request a limit on the medical
information we disclose about you to someone who is involved in your
care or the payment for your care. You also have the right to request
that we communicate with you about medical matters in a certain way.
For example, you can ask that we only contact you at work or by mail.
D. AMENDMENTS TO YOUR RECORDS: If you feel that medical
information we have about you is incorrect or incomplete, you may ask
us to amend the information. Such requests must be made in writing,
and must explain why the information should be amended. We may deny
your request under certain circumstances.
E. RIGHT TO A PAPER COPY OF THIS NOTICE: You have
the right to a paper copy of this notice. You may ask us to give you
a copy of this notice at any time.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions
or concerns, please contact us. If you are concerned that we may have
violated your privacy rights, you may complain to us using the contact
information listed below. You may also submit a written complaint with
the U.S. Department of Health and Human Services.
We support your right to privacy of your health information. We will
not retaliate in any way if you choose to file a complaint. Please direct
any of your questions or complaints to:
Texas Breast Care
Las Colinas Medical Center
Plaza One, 6750 N. MacArthur Blvd., Suite 205
Irving, TX 75039
Telephone:
972-284-0080
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