HIPAA NOTICE OF PRIVACY PRACTICES
I. 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.
II. IT IS A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
The law requires that your PHI is kept private. The PHI constitutes information created or noted by this office that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. This Notice about privacy procedures is required. This Notice must explain when, why, and how your PHI would be used and/or disclosed. Use of PHI means when information is shared, applied, utilized, examined, or analyzed within this office; PHI is disclosed when information is released, transferred, given, or otherwise revealed to a third party outside my practice. With some exceptions, your PHI will not be used or disclosed more than is necessary to accomplish the purpose for which the use or disclosure is made; however, following the privacy practices described in this Notice is always legally required.
Please note that the right to change the terms of this Notice and these privacy policies at any time is reserved. Any changes will apply to PHI already on file in this office. Before any important changes to policies are made, this Notice will be modified and a new copy of it posted in the office and on the website. You may also request a copy of this Notice from the office, or you can view a copy of it in the office or the website, which is located at http://www.victoriamartinmd.com/
For purposes of this Notice, the use of the word “office” should be taken to mean Dr. Victoria Martin, M.D. and her entire office staff. In all cases when the words “you” or “patient” are used, it should be taken to mean “the patient or their parent/legal guardian.”
III. HOW YOUR PHI WILL BE USED AND DISCLOSED.
Your PHI will be used and disclosed for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of uses and disclosures, with some examples.
A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. Your PHI may be used and disclosed without your consent for the following reasons:
For treatment. Your
health information may be used to give you medical treatment or
services. Your health information may be disclosed to pharmacists and
their assistants, and other professionals involved in your care to put
in place a treatment plan and to carry out that plan. For example, if
you or your child has ADHD, the doctor, or office staff may need to
clarify medication instructions with the pharmacy; obtain prior
authorization for certain medications from insurance entities; tell the
school nurse when to dispense medication. In some situations, your
health information may be disclosed to other health care facilities or
providers who will be treating you. For example, we may disclose health
information about you to people outside of this office who provide
follow-up care to you, such as physicians and in-patient treatment
For health care operations. Your
PHI may be disclosed to facilitate the efficient and correct operation
of this practice. Examples: Quality control - Your PHI might be
used in the evaluation of the quality of health care services that you
have received or to evaluate the performance of the health care
professionals who provided you with these services. Your PHI
may also be provided to attorneys, accountants, consultants, and
others to make sure of compliance with applicable laws.
To obtain payment for treatment.
Your PHI may be used and disclosed to bill and collect payment for the
treatment and services provided to you. Example: Your PHI might be
communicated to your insurance company or health plan in order to get
payment for the health care services that have been provided to you.
Your PHI may also be provided to business associates, such as billing
companies, claims processing companies, and others that process health
care claims for this office.
Other disclosures. Examples:
Your consent isn't required if you need emergency treatment provided
that this office attempts to get your consent after treatment is
rendered. In the event that this office tries to get your consent but
you are unable to communicate (for example, if you are unconscious or in
severe pain) but is reasonable to assume that you would consent to such
treatment if you could, your PHI may be disclosed.
Certain Other Uses and Disclosures Do Not Require Your Consent. Your
PHI may used and/or disclosed without your consent or authorization for
the following reasons:
disclosure is required by federal, state, or local law; judicial, board,
or administrative proceedings; or, law enforcement. Example:
This office may make a disclosure to the appropriate officials when a
law requires reporting information to government agencies, law
enforcement personnel and/or in an administrative proceeding.
disclosure is compelled by a party to a proceeding before a court of an
administrative agency pursuant to its lawful authority.
disclosure is required by a search warrant lawfully issued to a
governmental law enforcement agency.
disclosure is compelled by the patient or the patient’s representative
pursuant to Texas Health and Safety Codes or to corresponding federal
statutes of regulations,
such as the Privacy Rule that requires this Notice.
avoid harm. PHI
may be provided to law enforcement personnel or persons able to prevent
or mitigate a serious threat to the health or safety of a person or the
disclosure is compelled or permitted by the fact that you are in such
mental or emotional condition as to be dangerous to yourself or the
person or property of others, and if I determine that disclosure is
necessary to prevent the threatened danger.
disclosure is mandated by the Texas Child Abuse and Neglect Reporting
For example, if there is a reasonable suspicion of child abuse or
disclosure is mandated by the Texas Elder/Dependent Adult Abuse
For example, if there is a reasonable suspicion of elder abuse or
dependent adult abuse.
disclosure is compelled or permitted by the fact that you tell this
office of a serious/imminent threat of physical violence by you against
a reasonably identifiable victim or victims.
public health activities. Example:
In the event of your death, if a disclosure is permitted or compelled,
giving information about you to the county coroner may be needed.
For health oversight
This office may be required to provide information to assist the
government in the course of an investigation or inspection of a health
care organization or provider.
For specific government
PHI of military personnel and veterans may be disclosed under certain
circumstances. Also in the interests of national security, such as
protecting the President of the United States or assisting with
For research purposes. In
certain circumstances, PHI may be provided in order to conduct medical
Compensation purposes. PHI
may be provided in order to comply with Workers' Compensation laws.
and health related benefits or services. Examples:
PHI may be used to provide appointment reminders. PHI may be used to
give you information about alternative treatment options, or other
health care services or benefits offered.
an arbitrator or arbitration panel compels disclosure, when
arbitration is lawfully requested by either party, pursuant to subpoena duces
tectum (e.g., a subpoena for mental health records) or any other
provision authorizing disclosure in a proceeding before an arbitrator or
disclosure is required or permitted to a health oversight agency for
oversight activities authorized by law. Example:
When compelled by U.S. Secretary of Health and Human Services to
investigate or assess my compliance with HIPAA regulations.
If disclosure is
otherwise specifically required by law.
C. Other Uses and Disclosures Require Your Prior Written Authorization.
any other situation not described in Sections IIIA, IIIB, and IIIC
above, your written authorization will be requested before using or
disclosing any of your PHI. Even if you have signed an authorization to
disclose your PHI, you may later revoke that authorization, in writing,
to stop any future uses and disclosures.
WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
are your rights with respect to your PHI:
The Right to See and Get Copies of Your PHI. In
general, you have the right to see your PHI that is in my possession, or
to get copies of it; however, you must request it in writing. You will
receive a response from me within 15 days of my receiving your written
request. Under certain circumstances, your request may be denied. If so
you will receive the reason for denial in writing. You also have
the right to have the denial reviewed.
will be a charge for copying your PHI.
The Right to Request Limits on Uses and Disclosures of Your PHI. You
have the right to ask that use and disclosure of your PHI be limited and
how. While your request will be considered, this office is not legally
bound to agree. If your request is agreed to, those limits will be put
in writing and abided to except in emergency situations. You do not have
the right to limit the uses and disclosures that I am legally required
or permitted to make.
The Right to Choose How Your PHI is Sent to You. It
is your right to ask that your PHI be sent to you at an alternate
address (for example, sending information to your work address rather
than your home address) or by an alternate method (for example, via
email instead of by regular mail). This office is obliged to agree to
your request providing that the PHI can be rendered, in the format you
requested, without undue inconvenience.
The Right to Get a List of the Disclosures Made. You
are entitled to a list of disclosures of your PHI made by this office.
The list will not include uses or disclosures to which you have already
consented, i.e., those for treatment, payment, or health care
operations, sent directly to you, or to your family; neither will the
list include disclosures made for national security purposes, to
corrections or law enforcement personnel, or disclosures made before
April 15, 2003. After April 15, 2003, disclosure records will be
held for six years.
request for an accounting of disclosures will be responded to within 60
days of receiving your request in writing. The list will include
disclosures made in the previous six years (the first six year period
being 2003-2009) unless you indicate a shorter period. The list will
include the date of the disclosure, to whom the PHI was disclosed
(including their address, if known), a description of the information
disclosed, and the reason for the disclosure. The list is offered to you
at no cost, unless you make more than one request in the same year, in
which case a reasonable sum will be charged based on a set fee for each
The Right to Amend Your PHI. If
you believe that there is some error in your PHI or that important
information has been omitted, it is your right to request correction of
the existing information or addition of the missing information. Your
request and the reason for the request must be made in writing. You will
receive a response within 60 days of receipt of your request. Your
request may be denied, in writing, if: the PHI is (a) correct and
complete, (b) forbidden to be disclosed, (c) not part of the records, or
(d) written by someone other than this office. Denial must be in writing
and must state the reasons for the denial. It must also explain your
right to file a written statement objecting to the denial. If you do not
file a written objection, you still have the right to ask that your
request and the denial be attached to any future disclosures of your
PHI. If your request is approved, the change(s) will be made to your
PHI. Additionally, you will be told that the changes have been made, and
all others who need to know about the change(s) to your PHI will be
HOW TO COMPLAIN ABOUT PRIVACY PRACTICES
in your opinion, your privacy rights have been violated, or if you
object to a decision made about access to your PHI, you are entitled to
file a complaint with the person listed in Section VI below. You may
also send a written complaint to the Secretary of the Department of
Health and Human Services at 200 Independence Avenue S.W. Washington,
D.C. 20201. If you file a complaint about privacy practices, no
retaliatory action against you.
VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT PRIVACY PRACTICES
you have any questions about this notice or any complaints about my
privacy practices, or would like to know how to file a complaint with
the Secretary of the Department of Health and Human Services, please
contact: D. Victoria Martin, M.D. P.A., 1221 Abrams Road, Suite 100, Richardson, Texas 75081 --- (972) 994-0540, or firstname.lastname@example.org.
EFFECTIVE DATE OF THIS NOTICE
notice went into effect on April 14, 2003.