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 test 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 services. For example, your health plan may request and receive information on dates of service, the service 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 Urgent Care MD’s. 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 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 nor 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 government 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 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 federal privacy standards. These include:
- The right to request restrictions on the use and disclosure of you protected health information
- The right to receive confidential communications concerning your medical condition and treatment
- The right to inspect and copy your protected health information
- The right to amend or submit corrections to your protected health information
- The right to receive an accounting of how and to whom your protected health information has been disclosed
- The right to receive a printed copy of this notice
UrgentCare MD’s Duties
UrgentCare MD’s 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 to abide by the 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 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.
Requesting 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 at (281) 428-0000. 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, 1658 W. Baker St, Ste A, Baytown, TX 77521. 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 above.
You will not be penalized or otherwise retaliated against for filing a complaint.
If you believe that 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 at 1301 Young Street, Suite 1169, Dallas, TX, 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 omission 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.