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.
If you have any questions about this notice, please contact me at (512) 789-6244.
I am required by law to:
- Maintain the privacy of protected health information;
- Let you know promptly if a breach occurs that may have compromised the privacy or security of protected health information about you;
- Give you this notice of my legal duties and privacy practices regarding protected health information about you; and
- Follow the terms of my notice that is currently in effect.
HOW I MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION:
The following describes the ways I may use and disclose protected health information that identifies you. Except for the purposes described below, I will use and disclose protected health information only with your written permission. You may revoke such permission at any time by writing to the practice Privacy Officer.
For Treatment. I may use and disclose protected health information for your treatment and to provide you with treatment-related health care services. For example, I may disclose protected health information to doctors, nurses, technicians, or other personnel, including people outside my office, who are involved in your medical care and need the information to provide you with medical care. A specific authorization is required for me to share this information.
For Payment. I may use and disclose protected health information so that I or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, I may give your health plan information about you so that they will pay for your treatment.
For Health Care Operations. I may use and disclose protected health information for health care operations purposes. These uses and disclosures are necessary to make sure that all of my patients receive quality care and to operate and manage my practice. I also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities. Examples of health care operations include but are not limited to quality assessments and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination
Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. I may use and disclose protected health information to contact you to remind you that you have an appointment with me. I also may use and disclose protected health information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.
I am allowed or required to share your information in other ways – usually in ways that contribute to public good, such as public health and research. I have to meet many conditions in the law before I can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
As Required by Law. I will disclose protected health information when required to do so by international, federal, state or local law.
To Avert a Serious Threat to Health or Safety. I may use and disclose protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.
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 Family and Protective Services, the Texas Youth Commission, or to any local or state law enforcement agency.
Adult or 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 Family and Protective Services.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, I may disclose protected health information in response to a court or administrative order. I also may disclose protected health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. I may release protected health information if asked by a law enforcement official if the information is:
1. in response to a court order, subpoena, warrant, summons or similar process;
2. limited information to identify or locate a suspect, fugitive, material witness, or missing person;
3. about the victim of a crime even if, under certain very limited circumstances, I am unable to obtain the person’s agreement;
4. about a death I believe may be the result of criminal conduct;
5. about criminal conduct on my premises; and
6. in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Health Oversight Activities. I may disclose protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, eligibility or compliance, and to enforce health-related civil rights and criminal laws.
Data Breach Notification Purposes. I may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclosure of your protected health information.
Business Associates. I may disclose protected health information to my business associates that perform functions on my behalf or provide us with services if the information is necessary for such functions or services. For example, I may use another company to perform billing services and/or to maintain an electronic medical record on my behalf. All business associates are obligated to protect the privacy and security of your information and are not allowed to use or disclose any information other than as specified in our contract.
Organ and Tissue Donation. If you are an organ donor, I may use or release protected health information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, I may release protected health information as required by military command authorities. This might include but is not limited to fitness for military duties and eligibility for VA benefits. I didn’t see this on the one you created for me I also may release protected health information to the appropriate foreign military authority if you are a member of a foreign military.
Workers’ Compensation. I may release protected health information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. I may disclose protected health information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if I believe a patient has been the victim of abuse, neglect or domestic violence. I will only make this disclosure if you agree or when required or authorized by law.
Coroners, Medical Examiners and Funeral Directors. I may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. I also may release protected health information to funeral directors as necessary for their duties.
National Security and Intelligence Activities. I may release protected health information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.
Protective Services for the President and Others. I may disclose protected health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.
Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, I may release protected health information to the correctional institution or law enforcement official. This release would be if necessary:
1. for the institution to provide you with health care;
2. to protect your health and safety or the health and safety of others; or
3. the safety and security of the correctional institution.
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT
Individuals Involved in Your Care or Payment for Your Care. You have the right to tell me to share information with your family, close friends, or others involved in your care. If you are not able to tell me your preference, for example, if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.
Disaster Relief. I may disclose your protected health information to disaster relief organizations that seek your protected health information to coordinate your care, or notify family and friends of your location or condition in a disaster. I will provide you with an opportunity to agree or object to such a disclosure whenever I practically can do so.
Fundraising. I may contact you for fundraising efforts, but you can tell me not to contact you again.
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES
The following uses and disclosures of your protected health information will be made only with your written authorization:
1. Uses and disclosures of protected health information for marketing purposes;
2. Disclosures that constitute a sale of your protected health information; and
3. Mental and behavioral health records;
4. Records of drug, alcohol, or substance abuse treatment;
5. Records regarding HIV or AIDS diagnosis and treatment; and
6. Genetic information (including Genetic Tests).
Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you do give me an authorization, you may revoke it at any time by submitting a written revocation by mail to Mary Burke at 603 W. 14th St., Austin, TX 78701 and I will no longer disclose protected health information under the authorization. But disclosure that I made in reliance on your authorization before you revoked it will not be affected by the revocation.
You have the following rights regarding protected health information I have about you:
Right to Inspect and Copy. You have a right to inspect and copy protected health information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this protected health information, you must make your request, in writing, to Mary Burke at 603 W. 14th St., Austin, TX 78701. I have up to 15 business days to make your protected health information available to you and I may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. I may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. I may deny your request in certain limited circumstances. If I do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and I will comply with the outcome of the review.
Right to an Electronic Copy of Electronic Medical Records. If your protected health information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. I will make every effort to provide access to your protected health information in the form or format you request, if it is readily producible in such form or format. If the protected health information is not readily producible in the form or format you request your record will be provided in either a standard electronic format or if you do not want this form or format, a readable hard copy form. I may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record and for any media, such as flash drives or writable CDs, used to transmit your electronic medical record.
Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
Right to Amend. If you feel that protected health information I have is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment for as long as the information is kept by or for myself. To request an amendment, you must make your request, in writing, to Mary Burke at 603 W. 14th St., Austin, TX 78701. This request must include the reason that supports your request for an amendment. I may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask us to amend information that:
1. Was not created by myself, unless the person or entity that created the information is no longer available to make the amendment;
2. Is not part of the medical information kept by myself;
3. Is not part of the information which you would be permitted to inspect and copy; or
4. Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures I made of protected health information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Mary Burke at 603 W. 14th St., Austin, TX 78701. The request must state a time period, which may not be longer than 6 years. I will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information I use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the protected health information I disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that I not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, Mary Burke at 603 W. 14th St., Austin, TX 78701. This request must indicate: (1) what information you want to limit; (2) whether you want to limit me to use and/or disclosure; and (3) to whom you want the limits to apply.
I am not required to agree to your request unless you are asking me to restrict the use and disclosure of your protected health information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid me “out-of-pocket” in full. If I agree, I will comply with your request unless the information is needed to provide you with emergency treatment.
Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that I not bill your health plan) in full for a specific item or service, you have the right to ask that your protected health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and I will honor that request.
Right to Request Confidential Communications. You have the right to request that I communicate with you in a certain way or at a certain location. For example, you can ask that I only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to Candyce Ossefort-Russell at 2124 Bluebonnet Ln., Austin, TX 78704. Your request must specify how or where you wish to be contacted. I will accommodate reasonable requests.
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. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
CHANGES TO THIS NOTICE:
I reserve the right to change this notice and make the new notice apply to protected health information I already have as Ill as any information I receive in the future. I will post a copy of my current notice at my office.
If you believe your privacy rights have been violated, you may file a complaint with my office at the address below or with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. I will not retaliate against you for filing a complaint.
Candyce Ossefort-Russell, LPC-S
2124 Bluebonnet Lane
Austin, TX 78704
Whoever is careless with the truth in small matters cannot be trusted with important matters. — Albert Einstein