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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.
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 and on the website where it can be seen.
You can request a paper copy of this notice, or any
revised notice, at any time (even if you have allowed
us to communicate with you electronically). For more
information about this notice or our privacy practices
and policies, please contact our office. |
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| Treatment |
| We are permitted to use and disclose your medical
information to those involved in your treatment. For
example, 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. |
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| Payment |
| We are permitted to use and disclose your medical
information to bill and collect payment for the services
we provide to you. For example, we may complete a claim
form to obtain payment from your insurer or HMO. That
form will contain medical information, such as a description
of the medical services provided to you, that your insurer
or HMO needs to approve payment to us. |
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| 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. |
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There are situations in which we are permitted
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 that rely 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. |
| Because Texas law requires physicians to report child
abuse or neglect, we may disclose medical information
to a public agency authorized to receive reports of
child abuse or neglect. Texas law also requires a person
having cause to believe that an elderly or disabled
person is in a state of abuse, neglect, or exploitation
to report the information to the state, and HIPAA privacy
regulations 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. |
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| Legal Proceedings and Law Enforcement |
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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.
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| If asked by a law enforcement official, we may disclose
your medical information under limited circumstances
provided: |
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The information is released pursuant to legal
process, such as a warrant or subpoena; |
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The information pertains to a victim of crime
and you are incapacitated; |
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The information pertains to a person who has
died under circumstances that may be related to
criminal conduct; |
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The information is about a victim of crime and
we are unable to obtain the person’s agreement;
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The information is released because of a crime
that has occurred on these premises; or |
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The information is released to locate a fugitive,
missing person, or suspect. |
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| We also may release information if we believe the
disclosure is necessary to prevent or lessen an imminent
threat to the health or safety of a person. |
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| Workers’ Compensation |
| We may disclose your medical information as required
by workers’ compensation law. |
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| 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. |
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| 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. |
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| Research, Organ Donation, Coroners, Medical Examiners,
and Funeral Directors |
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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 person
or a cause of death. Further, we may release your
medical information to a funeral director when such
a disclosure is necessary for the director to carry
out his duties.
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| Required by Law |
| We may release your medical information when the disclosure
is required by law. |
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The U. S. 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
patients who exercise 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 health care 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. |
| You also may request that we limit disclosure to family
members, other relatives, or close personal friends
who may or may not be involved in your care. |
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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
at the end of this document.
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| Receiving Confidential Communications by Alternative
Means |
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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.
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| Inspection and Copies of Protected Health Information |
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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 at the
end of this document.
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We may ask that a narrative of that
information be provided rather than copies. However,
if you do not agree to our request, we will provide
copies.
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| We can refuse to provide some of the information you
ask to inspect or ask to be copied for the following
reasons: |
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The information is psychotherapy notes. |
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The information reveals the identity of a person
who provided information under a promise of confidentiality.
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The information is subject to the Clinical Laboratory
Improvements Amendments of 1988. |
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The information has been compiled in anticipation
of litigation. |
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We can refuse to provide access to or
copies of some information for other reasons, provided
that we arrange for a review of our decision on your
request. Any such review will be made by another licensed
health care provider who was not involved in the prior
decision to deny access.
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| Texas law requires us to be ready to provide copies
or a narrative within 15 days of your request. We will
inform you 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. |
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| 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 our office at the end of this
document. We will respond within 60 days of your request.
We may refuse to allow an amendment for the following
reasons: |
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The information wasn’t created by this
practice or the physicians in this practice. |
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The information is not part of the designated
record set. |
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The information is not available for inspection
because of an appropriate denial. |
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The information is accurate and complete. |
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| 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 now have the incorrect information. |
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| Accounting of Certain Disclosures |
| 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
at the end of this document. 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. |
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We may contact you by (telephone, mail, or
both) to provide appointment reminders, information about
treatment alternatives, or other health-related benefits
and services that may be of interest to you.
If you are concerned that your privacy rights
have been violated, you may contact our office. You may
also send a written complaint to the U. S. Department of
Health and Human Services. We will not retaliate against
you for filing a complaint with us or the government.
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.
If you have any questions or want to make
a request pursuant to the rights described above, please
contact:
| Bariatrics of Texas |
| ATTN: Angela Gibbons |
| #6 Eureka Circle |
| Wichita Falls, TX 76308 |
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| Phone: (940) 691-0805 |
Fax: (940) 691-0774
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| This notice is effective April 14, 2003. |
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