Page ContentNotice of Privacy Practices Kelsey-Seybold Clinic 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.If you have any questions about this Notice please contact our Privacy Office (713-442-5700)This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations 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 genetic information & demographic information, whether oral or recorded in any form or medium, that is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university or health care clearinghouse and relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website (www.kelsey-seybold.com), or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. 1. Uses and Disclosures of Protected Health Information Uses and Disclosures of Protected Health Information Based Upon Your Written ConsentFollowing are examples of the types of uses and disclosures of your protected health care information that the physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. 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 provider. For example, we would disclose protected health information to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include providing health information for making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. Health Care 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, marketing and fundraising activities, and conducting or arranging for other business activities.For example, we may use your protected health information to assess the quality of care at Kelsey-Seybold. We may use or disclose your protected health information, as necessary, for appointment reminders or to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Office to request that these materials not be sent to you.We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. Uses and Disclosures of Protected Health Information Based upon Your Written AuthorizationOther uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to ObjectWe may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed. Others Involved in Your Health Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts(such as the Red Cross) and to coordinate uses and disclosures to family or other individuals involved in your health care. Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physician or another physician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you. Communication Barriers: We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances. The following uses and disclosures will be made only with authorization from the patient/representative: (1) for use and disclosures for marketing purposes; (2) for use and disclosures that constitute the sale of PHI; (3) most uses and disclosures of psychotherapy notes (if maintained) and, (4) other uses and disclosures as required by law. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to ObjectWe may use or disclose your protected health information in the following situations without your consent or authorization. These situations include: Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. Public Health: We may disclose your protected health information to the CDC, the Texas Department of Health, and other public health authorities for public health activities as permitted by law. The disclosure will be made for the purpose of controlling disease, injury or disability. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose protected health information to the Texas Board of Medical Examiners, U.S. Department of Health and Human Services, or other health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Abuse or Neglect: We may disclose your protected health information to Child Protective Services, Adult Protective Services, or other governmental body that is authorized by law to receive reports of abuse or neglect. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to witnesses, defendants, or victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred. JPs, Coroners: We may disclose protected health information to a justice of the peace, coroner or medical examiner for identification purposes, determining cause of death or for the JP, coroner or medical examiner to perform other duties authorized by law. Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Safety: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs. 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 federal law. 2. Your RightsFollowing is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice use for making decisions about you. We will provide information in paper or electronic form based on your preference if we have the ability to do so. If not, the information will be provided in paper format and a reasonable costbased fee will be charged. This fee includes the cost of supplies, labor and delivery cost.A physician may deny access to health information if he determines that release of information could be harmful to the physical, mental, or emotional health of a patient or could endanger a patient. You have the right to request a restriction of your protected health information to your health plan when that information relates solely to a healthcare item or service for which you, or another person on your behalf (other than a health plan), has paid us in full. Kelsey-Seybold may release restricted protected healthcare information as “required by law”. 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 physician is not required to agree to a restriction that you may request. If physician 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. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by signing our restriction form. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Office. You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this 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. Please contact our Privacy Office to determine if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. You have a right to or will be notified of a breach of unsecured protected health care information. If a breach of your medical information occurs and if that information is unsecured (not encrypted), we will notify you with a brief description of what happened, a description of the health information that was involved, recommended steps you can take to protect yourself from harm and what steps we are taking in response to the breach and contact procedures so you can obtain further information. Right to Opt-Out of Fundraising Communications. If we conduct fundraising and we use communications like the U.S. Postal Service or electronic email for fundraising, you have the right to opt-out of receiving such communications from us. Please contact our Privacy Office to opt-out of fundraising communications if you chose to do so. 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 electronically. 3. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint.To file a written complaint with us, you may bring your complaint directly to our Privacy Office or you may mail it to the following address: KelseySeybold Clinic, HIM and Privacy Office, 560 Meyerland Plaza Mall, Houston, Texas 77096Notice published & becomes effective April 14, 2003. Notice revised August 2012. Notice revised June 2013.