HIPAA Notice of Privacy Practices
MCCAMEY COUNTY HOSPITAL DISTRICT
PO BOX 1200
MCCAMEY, TX 79752
PLEASE REVIEW CAREFULLY: THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION.
This notice was published and becomes effective on or before April 14. 2003.
This Notice is provided to you pursuant to the Health Insurance Portability and Accessibility Act of 1996 and its implementing regulations ("HIPAA'). This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
Uses and Disclosures of Protected Health InformationYour protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. As an example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. Another example would be your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may also use or disclose your protected health information, as necessary, to contact you for appointment reminders.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues, communicable health oversight, abuse or neglect, Food and Drug Administration requirements, legal proceedings, Law Enforcement, coroners, funeral directors, and organ donation, research, criminal activity, military activity and national security, Workers' Compensation, inmates, required uses and disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.
For Worker's Compensation: We may use or disclose your Health Information as necessary to comply with worker's compensation laws.
To Correctional Institutions or Law Enforcement Officials, if you are an inmate.
Other Permitted and Required Uses and Disclosures Will be made only with your consent, authorization or opportunity to object unless required by law.
You may revoke this authorization If you authorize us to use or disclose your Health Information for another purpose, you may revoke your authorization in writing at any time.
Your RightsFollowing is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your provider is not required to agree to a restriction that you may request If a provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
You have the right to obtain a paper copy of this notice from us upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
ComplaintsYou may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by our staff.
We will not retaliate against you for filing a complaint. We promise not to retaliate against you for any complaint you make to the government about our policy practices.
We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Privacy and Compliance Officer, Vicky Ashmore, or Security Officer Larry Rollins, in person, or by phone at our main phone number, (432) 652-8626.
Our DutiesWe are required by law to maintain the privacy of your Health Information and to provide your with a copy of this notice.
We are also required to abide by the terms of this notice.
We reserve the right to amend this notice at any time and to make the new notice provisions applicable to all your Health Information - even if it was created prior to the change in the notice. If such amendment is made, we will immediately display the revised notice at our office and on this website and provide you with a copy, at any time, upon request.
Contact InformationYou may contact Vicky Ashmore at (432) 652- 8626 Ext. 251 or via email at firstname.lastname@example.org
Your signature below serves as acknowledgement that you have received this Notice of our Privacy Practices.
Print Name: _________________________ Signature: _______________________________ Date: ___________