Notice of Privacy Practices |
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 Premier PainConsultants, PA North Office 18626 Hardy Oak Rd., Suite 215 San Antonio, 78258 Ph: (210) 616-9400 Medical Center Office 2425 Babcock Rd., Suite 108 SanAntonio, 78229 Ph: (210) 616-9400 South Office 102 Palo Alto Rd., Suite 320 San Antonio, 78211 Ph: (210) 616-9400 Southeast Office 4025 E. Southcross Rd., Suite 18 SanAntonio, 78222 Ph: (210) 616-9400 Email This Page | 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. This practice uses and disclosed health information about you for treatment. This information is used to obtain payment for treatment, administrative purposes, and to evaluate the quality of care that you receive. This notice describes our privacy practices. You can request a copy of this notice at anytime. For more information about this notice or our privacy practices and policies, please contact our office. Treatment, Payment, Health Care Operations We are permitted to use and disclose your medical information to those involved in your treatment. For example: the physicians in our office are specialists. When we provide treatment we may request that your primary care and/or referring physician share your medical information with us. Also, we may provide your primary care and/or referring physician information about your condition so that he or she can appropriately treat you for the other medical conditions, if any. Payment We are permitted to use and disclose your medical information to bill and collect payment for services provided to you. For example, we may complete a claim form to obtain payment from your insurance carrier. The form will contain medical information such as a description of the medical service provided to you that your insurance carrier needs to approve payment to us. Health Care Operations We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered. For example, we may engage the services of a professional to aid this practice in its compliance with regulations and the law. Disclosures That Can Be Made Without Your Authorization There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object. In other situations we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you may later revoke that authorization in writing to stop future uses and disclosures. However revocation will not apply to disclosures or uses already made or taken in reliance on that authorization. Public Health, Abuse or Neglect, and Health Oversight We may disclose your medical information for public health activities. Public health activities are mandated by federal, state or local government for the collection of information about disease, vital statistics (births & death), or injury by a public health authority. We may disclose medical information, if authorized by law, to a person who may have been exposed to disease or may be at risk for contracting or spreading a disease or condition. We may disclose your medical information to report reactions to medications, problems with products that may be recalled. We may also disclose medical information to a public agency authorized to receive reports on child abuse or neglect. Texas law requires physicians to report child abuse or neglect. Regulations also permit the disclosure of information to report abuse or neglect of elders or the disabled. We may disclose your medical information to a health oversight agency for those activities authorized by law. Examples of these activities are audits, investigations, licensure application and inspections which are all government activities undertaken to monitor the healthcare delivery system and compliance with other laws, such as civil rights laws. Legal Proceedings and Law Enforcement We may disclose your medical information in the course of judicial or administrative proceedings in response to an order of the court (or the administrative decision-maker) or of the appropriate legal process. Certain requirements must be met before the information is disclosed. If asked by a law enforcement official we may disclose your medical information under the limited circumstances provided that the information: 1. is released pursuant to legal process, such as a warrant or subpoena 2. pertains to a victim of crime and you are incapacitated 3. pertains to a person who has died under circumstances that may be related to criminal conduct 4. is about a victim of crime and we are unable to obtain the person’s agreement 5. is released because of a crime that has occurred on these premises or is released to locate a fugitive, missing person or suspect. We may also release information if we believe the disclosure is necessary to prevent or relieve immediate threat to the health or safety of a person. Workers’ Compensation We may disclose your medical information as required by the Texas worker’s compensation acts. Inmates If you are an inmate or under the custody of law enforcement, we may release your medical information to the correctional institution or law enforcement official. This release is permitted to allow the institution to provide you with medical care, to protect your health, the safety of others or for the safety and security of the institution. Military, National Security and Intelligence Activities, Protection of the President We may disclose your medical information for specialized governmental functions such as separation or discharge from military service, request by appropriate military command officers (if you are in the military), authorized national security and intelligence activities; as well as authorized government officials, or foreign head of state. Organ Donation, Coroners, Medical Examiners, and Funeral Directors When a research projects and its privacy protections have been approved by an Institutional Review Board or privacy board, we may release medical information to researchers for research purposes. We may release medical information to organ procurement organizations for the purpose of facilitating organ, eye or tissue donation if you are a donor. Also we may release your medical information to a coroner or medical examiner to identify a deceased or a cause of death. Further, we may release your medical information to a funeral director where such disclosure is necessary for the director to carry out his duties. Required by Law We may release your medical information where the disclosure is required by law. Your Rights Under Federal Privacy Regulations The United States Department of Health and Human Services created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability (HIPAA). Those regulations create several privileges that patients may exercise. We will not retaliate against a patient that exercises their HIPAA rights. Requested Restrictions You may request that we restrict or limit how your protected health information is disclosed for treatment, payment, or healthcare operations. We do NOT have to agree to restriction, but if we do agree, we will comply with your request except under emergency circumstances. To request a restriction, submit the following in writing: (a) the information to be restricted, (b) what kind of restriction you are requesting (i.e. on the use of information, disclosed information or both), and (c) to whom the limits apply. Please send the request to the office and person listed below. You may also request that we limit disclosure to family members, other relatives, or personal friends that may or may not be involved in your care. Receiving Confidential Communications by Alternative Means You may request that we send communications of protected health information by alternative means or to an alternative location. This request must be made in writing to the person listed below. We are required to accommodate only reasonable requests, Please specify in your correspondence exactly how you want us to communicate with you and, if you are directly sending it to a particular place, the contact/address information. Inspection and Copies of Protected Health Information You may inspect and/or copy health information that is within the designated record set or the information that is used to make decisions about your care. Texas law requires that requests for copies be made in writing and we ask that requests for inspection of your health information also be made in writing. Please send your request to the person listed below. We can refuse to provide some of the information you ask to inspect or ask to be copied if the information: • Includes psychotherapy notes. • Includes the identity of a person who provided information if it was obtained under a promise of confidentiality. • Is subject to the Clinical Laboratory Improvements Amendments of 1988. • Has been compiled in anticipation of litigation. We can refuse to provide access to or copies of some information for other reasons, provided that we provide a review of our decision on your request. Another licensed health care provider who was not involved in the prior decision to deny access will make such review. Texas law requires that we will be ready to provide copies or a narrative within 15 days of your request. We will inform you of when the records are ready or if we believe access should be limited. If we deny access, we will inform you in writing. HIPPA permits us to charge a reasonable cost based fee. The Texas State Board of Medical Examiners (TSBME) has set limits on fees for copies of medical records that under some circumstances may be lower than the charges permitted by HIPPA. In any event, the lower of the fee permitted by HIPPA or the fee permitted by the TSBME will be charged. Amendment of Medical Information You may request an amendment of your medical information in the designated record set. And such request must be made in writing to the person listed below. We will respond within 60 days of such request. We may refuse to allow an amendment if the information: • Wasn’t created by this practice or the physicians here in this practice. • Is not part of the Designated Record Set? • Is not available for inspection because of an appropriate denial. • If the information is accurate and complete. Even if we refuse to allow an amendment you are permitted to include a patient statement about the information at issue in your medical record. If we refuse to allow an amendment we will inform you in writing. If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we know they have the incorrect information. Accounting of Certain Disclosures The HIPPA privacy regulations permit you to request, and us to provide, an accounting of disclosures that are other than for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for an account to the person listed below. Your first accounting of disclosures (within a 12 month period) will be free. For additional requests within that period we are permitted to charge for the cost of providing the list. If there is a charge we will notify you and you may choose to withdraw or modify your request before any costs are incurred. Appointment Reminders, Treatment Alternatives, and Other Health-related Benefits We may contact you by telephone, mail, or both to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you. Complaints If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United States Department of Health and Human Services is: U.S. Department of Health and Human Services HIPPA Complaint 7500 Security Blvd., C5-24-04 Baltimore, MD 21244 Our Promise to You We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protected health information and to abide by the terms of the notice of privacy practices in effect. Questions and Contact Person for Requests If you have any questions or want to make a request pursuant to the rights described above, please contact: Rose Marie McClellan, Privacy Officer 2425 Babcock Road San Antonio, Texas 78229 Phone: 210-616-9400 Fax: 210-616-9402 Email: info@painreliefdoctor.com This notice is effective on the following date: November 11, 2008 We may change our policies and this notice at any time and have those revised policies apply all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. |
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