Collom & Carney Clinic Association
NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
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
If you should have any questions about this notice, please contact:
Compliance/Privacy Officer at 903-614-3102
WHO WILL FOLLOW THIS NOTICE?
Any health care professional that is authorized to enter or retrieve information into your clinic records.
All employees of the clinic.
All departments of Collom and Carney Main Clinic, the pharmacy and other locations. All these locations follow the terms of this Notice. In addition these locations share medical information with each other for treatment, payment or clinic operations purposes described in this Notice.
We understand that medical information about you and your health is personal and we are committed to protecting this information. We create a record of the care and services you receive at the clinic. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, plan for future care or treatment, and billing record. This record serves as a:
We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated or received by the clinic.
This notice will tell you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to:
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we may use and disclose your medical information. We will explain what we mean and give some examples for each category of uses or disclosures. It is not possible to list every use or disclosure in each category. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
We will make these disclosures when required or authorized by law to do so. Where required by law, we will inform you that we have made such disclosures. All such disclosure will be made in accordance with the requirements of state and federal law and regulations.
Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. Health oversight agencies include public and private agencies authorized by law to oversee the health care system. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, eligibility or compliance, and to enforce health-related civil rights and criminal laws.
Lawsuits and Disputes. If you are involved in certain lawsuits or administrative disputes, we may disclose medical information about you in response to a court order or administrative order. With your authorization, or in cases where the law requires that we release your medical information, we may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process.
Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner when authorized by law. For example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the clinic to funeral directors as necessary to carry out their duties.
Inmates. If you are an inmate of a correctional facility, we may release medical information about you to the correctional facility for the facility to provide you with health care.
Other Uses or Disclosures. Any other use or disclosure of PHI will be made only upon your individual written authorization. This includes but is not limited to, records for your personal files, insurance companies for coverage applications, attorneys, family members, other medical facilities that are not currently involved in your medical care. You may revoke an authorization at any time provided that it is in writing and we have not already relied on the authorization.
Breach of Your Medical Information. In the event that your medical or billing is accidentally lost or given to an unauthorized individual or business, we are required by law to notify you by certified mail within 30 days of discovery.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding medical in we collect and maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually this includes medical and billing records but does not include psychotherapy notes. Your written authorization is required to receive a copy of your psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to The Director of Health Information Management, Collom & Carney Clinic Association, 5002 Cowhorn Creek Rd., Texarkana, TX 75503. If you request a copy of the information we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, including psychotherapy notes, you may request that the denial be reviewed. Another licensed health care professional chosen by the clinic will review your request and denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by the clinic. To request an amendment, your request must be made in writing and submitted to the Director of Health Information Management, Collom & Carney Clinic Association, 5002 Cowhorn Creek Rd., Texarkana, TX 75503. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures”. This is a list of the disclosures we made of your medical in, without your authorization, or purposes other than treatment, payment or health care operations.
To request this list you must submit your request in writing to the Director of Health Information Management, Collom & Carney Clinic Association, 5002 Cowhorn Creek Rd., Texarkana, TX 75503. Your request must state a time period which may not be longer then six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional list within the 12 month period, we may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations, You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care.
We are not required to agree to your request. If we do, we will comply with your request unless the Information is needed to provide you emergency treatment.
To request restrictions you must make your request in writing to the Compliance/Privacy Officer, Collom & Carney Clinic Association, 5002 Cowhorn Creek Rd., Texarkana, TX 75503. In your request you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both: and (3) to whom you want the limits to apply, for example, disclosures to your spouse.(4) If you pay for a service or health care item out-of-pocket in full, you can request not to share that information for the purpose of payment or our operations with your health insurer.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example you can ask that we only contact you at work or by mail to request confidential communications or a change to an already existing request, you must make your request in writing to the Compliance Privacy Officer, Collom & Carney Clinic Association, 5002 Cowhorn Creek Rd., Texarkana, TX 75503. You do not have to state a reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted
CHANGES TO THIS NOTICE.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our protected health information practices change, a revised Notice will be available on our website at www.collom- carney.com. You may request that a copy be provided to you by contacting the Compliance/Privacy Officer, Collom & Carney Clinic Association, 5002 Cowhorn Creek Rd., Texarkana, TX 75503.
If you believe your privacy rights have been violated or if you disagree with a decision we made about access to your records, you may file a complaint with the clinic or with the Secretary of the Department of Health and Human Services (“HHSC”). To file a complaint with the clinic, contact:
Collom & Carney Clinic Association
P.O. Box 1409
Texarkana, TX 75504
Your complaint must be filed within 180 days of when you knew or should have known that the act occurred. The address for the Office of Civil Rights is:
Region VI, Office for Civil Rights
U.S. Department of Health and Human Services
1301 Young Street, Suite 1169
Dallas, TX 75202
All Complaints should be submitted in writing.
For complaints filed by e-mail, send to: OCRComplaints@hhs.gov
You will NOT be penalized for filing a complaint.
This Notice is effective as of April 14, 2003.