Pondworks Notice of Privacy Practices
The privacy of your medical information is important to our office. We understand that your medical information is personal, and we are committed to protecting it. We create a record of the care and services you receive in this office. We need this record to provide you with quality care and to comply with certain legal requirements.
This notice describes how medical information about you may be used and how you can get access to this information. PLEASE REVIEW IT CAREFULLY. This notice takes effect on August 5th, 2013 and remains in effect until we replace it. Before any important changes are made in the privacy practices, our office will change this notice and make the new notice available.
Pondworks' Notice of Privacy Practices is available here and as a more legible, 4-page PDF on our website. This document describes the ways we may use and share medical information about you. It also describes your rights and certain duties this office has regarding the use and disclosure of medical information. The PDF version of this notice may be found on our website, www.pondworkspsychiatry.com/other-clinical-forms
1. OUR PLEDGE REGARDING MEDICAL INFORMATION:
The privacy of your medical information is important to our office. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive in this office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. It also describes your rights and certain duties this office has regarding the use and disclosure of medical information.
2. OUR LEGAL DUTY
Law Requires Our Providers to: 1) Keep your medical information private. 2) Give you notice describing legal duties, privacy practices, and your rights regarding your medical information. 3) Follow the terms of the current notice.
We Have the Right to: 1) Change privacy practices and the terms of this notice at any time, provided that law permits the changes. 2) Make the changes in the privacy practices and the new terms of the notice effective for all medical information that is kept, including information previously created or received before the changes.
3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways that our providers use and disclose medical information. Not every use or disclosure will be listed. However, this explanation has listed all of the different ways our office is permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice.
FOR TREATMENT: Our providers may use medical information about you to provide you with medical treatment or services. Our office may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you.
FOR PAYMENT: Our office may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.
FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we may need to serve you.
ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment and health care operations, we may use and disclose medical information for the following purposes.
NOTIFICATION: Our office may use and disclose medical information to notify or help notify: a family member, your personal representative or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, our office will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to the professional judgment of the practitioner. Our practitioners will also use their professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information for you.
DISASTER RELIEF: We may share medical information with a public or private organization or person who can legally assist in disaster relief efforts.
RESEARCH IN LIMITED CIRCUMSTANCES: We may use medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information.
FUNERAL DIRECTOR, CORONER, MEDICAL EXAMINER: To help them carry out their duties, our office may share the medical information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.
SPECIALIZED GOVERNMENT FUNCTIONS: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
COURT ORDERS AND JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: Our office may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. We may share the medical information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.
PUBLIC HEALTH ACTIVITIES: As required by law, our office may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.
VICTIMS OF ABUSE, NEGLECT OR DOMESTIC VIOLENCE: Our office may use and disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. We may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.
WORKERS COMPENSATION: We may disclose health information when authorized or necessary to comply with laws relating to workers compensation or other similar programs.
HEALTH OVERSIGHT ACTIVITIES: We may disclose medical information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.
LAW ENFORCEMENT: Under certain circumstances, our office may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
APPOINTMENT REMINDERS: Our office may use and disclose medical information for purposes of sending you appointment postcards or otherwise reminding you of your appointments.
ALTERNATIVE AND ADDITIONAL MEDICAL SERVICES: We may use and disclose medical information to furnish you with information about health-related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives.
4. YOUR INDIVIDUAL RIGHTS
You Have A Right to: 1) Look at or get copies of certain parts of your medical information. You may request that our office provide copies in a format other than photocopies. We will use the format you request unless it is not practical for our office to do so. You must make your request in writing using Pondworks Release of Information (ROI) form. If you request copies, we reserve the right to charge you $35.00 for each request, plus postage.
2) Receive a list of all the times Pondworks has shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions.
3) Request that our office place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).
4) Request that we communicate with you about your medication information by different means or to different locations. Your request that our office communicate your medical information to you by different means or at different locations must be made in writing to the contact person listed at the end of this notice.
5) Request that we change certain parts of your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.
6) If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by request.
QUESTIONS AND/OR COMPLAINTS
If you have any questions about this notice or if you think that our office may have violated your privacy rights, please contact us.
You may also submit a written complaint to the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint. To submit a complaint or submit requests involving any of your rights in Section 4 of this notice, write to the following addresses:
Pondworks, P.A. 3636 Executive Center Dr., Suite G-70 Austin, TX 78731
Office for Civil Rights U.S. Department of Health & Human Services 1301 Young Street - Suite 1169 Dallas, TX 75202 (214) 767-4056; (214) 767-8940 (TDD) (214) 767-0432 FAX
For more information, see http://www.hhs.gov/ocr/privacyhowtofile.htm
PATIENT PRIVACY PRACTICES ACKNOWLEDGMENT AND AGREEMENT
I have received the Notice of Privacy Practices, and have been provided an opportunity to review it.