NOTICE OF PRIVACY PRACTICES
Page 2
Effective
April 14, 2003
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.
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Our Responsibilities
Our practice is required to:
Maintain the privacy of your health information,
Provide you with this notice as to our legal duties and
privacy practices with respect to information we collect
and maintain about you,
Abide by the terms of this notice,
Notify you if we are unable to agree to a requested
restriction, and
Accommodate reasonable requests you may have to
communicate your health information.
We reserve the right to change our practices and to
make the new provisions effective for all protected health
information we maintain. We will keep a posted copy of the
most current notice in our
facility containing the effective
date in the top,
right-hand corner. In addition, each time
you visit our
facility for treatment, you may obtain a copy
of the current notice in effect upon request.
We will not use or disclose your health information in a
manner other than described
in the section regarding
Examples Of Disclosures For Treatment, Payment, And
Health Operations, without your written authorization,
which you may revoke as provided
by 45 CFR 164.508(b)(5),
except to the extent that action has already been taken.
For More Information or To Report A Problem
If you have questions and would like additional information, you may contact our practice's Privacy Officer,
1700 Mistletoe Blvd.
Ft. Worth
TX
76104
, Phone 817-927-2612.
If you believe your privacy rights have been violated, you can either file a complaint with the Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services (OCR). There will be no retaliation for filing a complaint with either our practice or the OCR. The address for the OCR is as follows:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
Examples of Disclosures for Treatment, Payment, and Health Care
Operations
We will use your health information for treatment.
We may provide medical information about you to
health care providers, our practice personnel,
or third
parties who are involved in the provision, management,
or coordination of your care.
For example:
Information obtained by a nurse, physician, or other
member of your health care team will
be recorded in your
record and used to determine the course of treatment that
should work
best for you. Your medical information will
be shared among health
care
professionals involved in
your care.
We will also provide your other physician(s) or subsequent
health care
provider(s) (when applicable) with copies of
various reports that should assist them in treating you.
We will use your health information for payment.
We may disclose your information so that we can collect
or make payment for the health
care services you receive.
For example:
If you participate in a health insurance plan, we will disclose necessary information to that plan to obtain payment for your care.
We will use your health information for regular health
operations.
We may disclose your health information for our routine
operations. These uses are necessary for certain
administrative, financial, legal, and quality improvement
activities that are necessary
to run our practice and
support the core functions.
For example:
Members of the quality improvement team may use information in your health record to assess the care
and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality
and effectiveness of the healthcare and service we provide and to reduce health care costs.
Continued
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