Notice of Privacy Practices (HIPAA) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE(Required) I have reviewed Notice of Privacy Practices which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of your Notice of Privacy Practices. We respect patient confidentiality and only release personal health information about you in accordance with the State of Texas and federal law. This notice describes our policies related to the use of the records of your care and how you may get access to this information. Please review this policy carefully. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION: In order to effectively provide care, there are times when we will need to share your personal health information with others beyond the practice for: TREATMENT. With your permission, we may use or disclose personal health information about you to provide, coordinate, or manage your care or any related services, including sharing information with others outside of the practice with whom we are consulting or to whom we are referring you. PAYMENT. Information will be used to obtain payment for the treatment and services provided. This will include contacting your health insurance company for proper approval of planned treatment or for billing purposes. OPERATIONS. We may use information about you to coordinate our business activities. This may include reviewing your care and training staff, budgeting and financial reporting, as well as activities to evaluate and promote quality. INFORMATION DISCLOSED WITHOUT YOUR CONSENT: Under state and federal law, information about you may be disclosed without your consent in the following circumstances: EMERGENCIES. Sufficient information may be shared to address the immediate emergency you are facing. FOLLOW-UP APPOINTMENT/CARE. We will be contacting you to remind you of future appointments, or information about treatment alternatives, or other health-related benefits and services that may be of interest to you. AS REQUIRED BY LAW. This would include situations where we have a subpoena, court order, or are mandated to provide public health information, such as communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or institutional abuse. CORONERS, FUNERAL DIRECTORS. We may disclose personal health information to a coroner or personal health examiner and funeral directors for the purposes of carrying out their duties. GOVERNMENTAL REQUIREMENTS. We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure. There might also be a need to share information with the Food and Drug Administration related to adverse events or product defects. We are also required to share information, if requested, with the Departmentof Health and Human Services to determine our compliance with federal laws related to health care. CRIMINAL ACTIVITY OR DANGER TO OTHERS. If a crime is committed on our premises or against our personnel, we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement and to warn any potential victims when we believe an immediate danger may exist to someone, or if we believe you present a danger to yourself. PATIENT RIGHTS AND RESPONSIBILITIES. You have the following rights under state and federal law: Copy of Record. You are entitled to inspect the personal health record we have generated about you. We may charge you a reasonable fee for copying and mailing your record. Effective January 2019 Patient Name(Required) First Last Parent/Guardian Signature(Required) Today's Date(Required) MM slash DD slash YYYY Relationship to Patient(Required)
