WE ARE REQUIRED BY FEDERAL LAW TO KEEP YOUR HEALTH CARE INFORMATION PRIVATE. THIS
NOTICE TELLS YOU HOW WE CAN USE YOUR INFORMATION AND WHAT YOUR RIGHTS ARE. WE ARE
REQUIRED BY LAW TO ABIDE BY THE TERMS OF THIS NOTICE.
REQUEST AN ACCOUNTING FOR OUR USE AND DISCLOSURES
OF YOUR PHI DURING THE LAST 6 YEARS BEGINNING ON APRIL 14, 2003, THE DATE WHEN HIPAA
PRIVACY PROVISIONS TAKE EFFECT. However, we will not be required to account
for use and disclosures prior to April 14, 2002. We do not have to account to you
for disclosures made in connection with your treatment, for payment, health care
operations or disclosures that we were required by law to make. You have the right
to one free accounting in any 12 month period; for additional accountings we may
charge a reasonable fee.
RECEIVE CONFIDENTIAL COMMUNICATIONS FROM US. If you want us only to contact you
at an alternative address, telephone number, or email address, you can request that
we do so and we will abide by your request.
WE WILL NOT RETALIATE AGAINST YOU IN ANY WAY FOR EXERCISING ANY OF YOUR RIGHTS UNDER
THE PERSON FOR YOU TO CONTACT WITHIN OUR ORGANIZATION IF YOU HAVE ANY QUESTIONS
OR COMPLAINTS, AND TO EXERCISE ANY RIGHTS YOU HAVE UNDER HIPAA IS:
3110 S. Great Southwest Parkway
Grand Prairie, TX 75052
YOU HAVE A RIGHT TO OBTAIN A COPY OF THIS NOTICE IN WRITING BY CONTACTING ANY EMPLOYEE
We will ask you to sign an acknowledgement that you have received this notice. If
you cannot do so, we will make a reasonable attempt later to obtain your acknowledgment.
Effective Date of this Notice: April 14, 2003
We may use your Protected Health Information (PHI) in the following ways without
your consent or authorization:
Consent refers to how we can use your information.
Authorization refers to when we pass your information along to others.
FOR YOUR TREATMENT. Without your consent or authorization, we will use PHI about
you to treat you. We will try to get a written consent from you if we can, but in
emergencies or when we can’t reasonably get a signed consent from you we may
use your information without it. We will pass your PHI along to other medical personnel
involved in your care, including doctors and nurses at treatment facilities you
may be taken to. We may use radio, telephone, fax, written, and computer communications
to transmit this information as needed for your care. Copies of your patient care
records will be given to people at facilities who treat you. We can disclose information
about you to your relatives, friends, and to other individuals who have a need to
know about your condition.
FOR PAYMENT. Without your consent or authorization, we will submit your PHI to insurance
companies, to Medicare or Medicaid as appropriate to obtain payment for our services
to you. We may use an outside billing company to process our claims for payment.
We may use your PHI for determining medical necessity for your treatment, for justifying
our treatments of you for payment purposes, and when an insurance company or other
payer requests further information about you to determine our rights to payment.
We may transmit your PHI to a collection agency hired by us to collect past due
We have the right to amend this notice, but no amendments may go into effect until
the amended notice has been posted.