TEXAS URGENT CARE ASSOCIATES, P.A.
NOTICE OF PRIVACY PRACTICES
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.
Uses and Disclosures
Treatment: Your health information may be used by staff members or disclosed
to other health care professionals for the purpose of evaluating your health,
diagnosing medical conditions, and providing treatment. For example, results
of laboratory tests and procedures will be available in your medical record
to all health professionals who may provide treatment or who may be consulted
by staff members.
Payment: Your health information may be used to seek payment from your health
plan, from other sources of coverage such as an automobile insurer, or from
credit card companies that you may use to pay for services. For example,
your health plan may request and receive information on dates of service,
the services provided, and the medical condition being treated.
Health care operations: Your health information may be used as necessary
to support the day-to-day activities and management of Texas Urgent Care.
For example, information on the services you received may be used to support
financial reporting, and activities to evaluate and promote quality.
Legal proceedings and law enforcement: Your health information may be disclosed
to law enforcement agencies to support government audits and inspections,
to facilitate law-enforcement investigations, and to comply with government-mandated
reporting.
Public health reporting: Your health information may be disclosed to public
health agencies as required by law. For example, we are required to report
certain communicable diseases to the state’s public health department.
Other uses and disclosures not requiring authorization:
Your health information may also be disclosed as required by the Texas workers’ compensation
law, if you are an inmate or under the custody of law enforcement, for specialized
governmental functions such as military, national security and intelligence
activities, or protection of the President, for research projects approved
by an Institutional Review Board or privacy board, for organ donation, to
coroners or medical examiners to identify a deceased or cause of death, and
to funeral directors when disclosure is necessary for the director to carry
out his duties.
Other uses and disclosures requiring your authorization: Disclosure of your
health information or its use for any purpose other than those listed above
requires your specific written authorization. If you change your mind after
authorizing a use or disclosure of your information, you may submit a written
revocation of the authorization. However, your decision to revoke the authorization
will not affect or undo any use or disclosure of information that occurred
before you notified us of your decision to revoke your authorization.
Individual Rights
You have certain rights under the federal privacy standards. These include:
Texas Urgent Care Duties
Texas Urgent Care is required by law to maintain the privacy of your protected
health information and to provide you with this notice of privacy practices.
We also are required to abide by the privacy policies and practices that
are outlined in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy
policies and practices. These changes in our policies and practices may
be required by changes in federal and state laws and regulations. Upon
request, we will provide you with the most recently revised notice on any
office visit. The revised policies and practices will be applied to all
protected health information we maintain.
Requests to Inspect Protected Health Information
You may generally inspect or copy the protected health information that we
maintain. As permitted by federal regulation, we require that requests
to inspect or copy protected health information be submitted in writing.
You may obtain a form to request access to your records by contacting our
Administrative Coordinator at the front desk or our Practice Manager. Your
request will be reviewed and will generally be approved unless there are
legal or medical reasons to deny the request. We must respond to your request
within 60 days from the date the request is submitted.
Complaints or Contact Person
If you would like further information concerning our privacy practices, you
may write or call our Practice Manager (512 326 2243). If you would like
to submit a comment or complaint about our privacy practices, you can do
so by sending a letter outlining your concerns to: Practice Manager, Texas
Urgent Care Associates, P.A., 2100 W. William Cannon Drive, Suite C, Austin,
Texas, 78745.
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address as above.
You will not be penalized or otherwise retaliated against for filing a complaint.
If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services, Region VI, Office for Civil Rights, U.S. Department of Health and Human Services, 1301 Young Street, Suite 1169, Dallas, Texas, 75202. Complaints to the Secretary must be in writing, either on paper or electronically, must name the entity that is the subject of the complaint, must describe the acts or omissions in violation, and must be filed within 180 days of when you knew, or should have known, that the act or omission occurred, unless this time limit is waived by the Office of Civil Rights for good cause shown. Complaints sent by email should be sent to: OCRComplaint@hhs.gov.
Effective Date
This notice is effective on April 14, 2003.
Acknowledgment
I acknowledge that I have received the Texas Urgent Care Notice of Privacy
Practices.
Patient/Parent/Guardian Signature |
Printed Name |
Date |