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HIPAA
Notice of Privacy Practices
Harris County Hospital District
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 CAREFULLY
If you have any questions about this notice,
please contact the HCHD Privacy Officer at
Harris County Hospital District
Office of Privacy Administration
2525 Holly Hall
Houston, TX 77054
713-566-6097
hipaa@hchd.tmc.edu
WHO WILL FOLLOW THIS NOTICE.
This notice describes the Harris County Hospital District’s (HCHD)
practices and that of:
- Any health care professional authorized
to enter information into your hospital chart.
- All departments and units of the
Hospital District.
- Any member of a volunteer group we allow
to help you while you are in the Hospital District Facilities.
- All employees, staff and other Hospital
District personnel.
- All the entities, sites and locations
listed below will follow the terms of this notice. In addition, these
entities, sites and locations may share medical information with each
other for treatment, payment or healthcare operations purposes described
in this
notice.
- All Harris County Hospital District
Facilities and extended health care service locations
- All Harris County Hospital District
Medical Staff
- The following entities are
participating in an Organized Healthcare Arrangement with the
Harris County Hospital District.
- Baylor College of Medicine
- The University of Texas Health
Sciences Center at Houston
- Craven & Plummer
- Lepow & Associates
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is
personal. We are committed to protecting medical information about you. We
create a record of the care and services you receive at the hospital. 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 by the Hospital District, whether made by Hospital
District personnel or your Hospital District doctors. Other doctors may
have different policies or notices regarding the doctor's use and
disclosure of your medical information created in the doctor's office or
clinic.
This notice will tell you about the ways in which we may use and disclose
medical information about you. We also describe your rights and certain
obligations we have regarding the use and disclosure of medical
information.
We are required by law to:
- Make sure that medical
information that identifies you is kept private;
- Give you this Notice of our
legal duties and privacy practices with respect to medical
information about you; and
- Follow the terms of the
Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL
INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose
medical information. For each category of uses or disclosures we will
explain what we mean and try to give some examples. Not every use or
disclosure in a category will be listed. However, all of the ways we are
permitted to use and disclose information will fall within one of the
categories. Some of the uses and disclosures listed below require your
authorization or your agreement.
- For Treatment. We may use
medical information about you to provide you with medical
treatment or services. We may disclose medical information
about you to doctors, nurses, technicians, medical
students, or other hospital personnel who are involved in
taking care of you at the hospital. For example, a doctor
treating you for a broken leg may need to know if you have
diabetes because diabetes may slow the healing process. In
addition, the
doctor may need to tell the dietitian if you have diabetes
so that we can arrange for appropriate meals. Different
departments of the hospital also may share medical
information about you in order to coordinate the different
things you need, such as prescriptions, lab
work and x-rays. We also may disclose medical information
about you to people outside the hospital who may be
involved in your medical care after you leave the
hospital, such as family members, clergy or others we use
to provide services that are part of your care.
- For Payment. We may use
and disclose medical information about you so that the
treatment and services you receive at the hospital may be
billed to and payment may be collected from you, an
insurance company or a third party. For example, we may
need to give your health plan information about surgery
you received at the hospital so your health plan will pay
us or reimburse you for the surgery. We may also tell your
health plan about a treatment you are going to receive to
obtain prior approval or to determine whether your plan
will cover the treatment.
- For Health Care
Operations. We may use and disclose medical information
about you for hospital operations. These uses and
disclosures are necessary to run the hospital and make
sure that all of our patients receive quality care. For
example, we may use medical information to review our
treatment and services and to evaluate the performance of
our staff in caring for you. We may also combine medical
information about many hospital patients to decide what
additional services the hospital should offer, what
services are not needed, and whether certain new
treatments are effective. We may also disclose information
to doctors, nurses, technicians, medical students, and
other hospital personnel for review and learning purposes.
We may also combine the medical information we have with
medical information from other hospitals to compare how we
are doing and see where we can make
improvements in the care and services we offer. We may
remove information that identifies you from this set of
medical information so others may use it to study health
care and health care delivery without learning who the
specific patients are.
- Appointment Reminders. We
may use and disclose medical information to contact you as
a reminder that you have an appointment for treatment or
medical care at the hospital.
- Treatment Alternatives. We
may use and disclose medical information to tell you about
or recommend possible treatment options or alternatives
that may be of interest to you.
- Health-Related Benefits
and Services. We may use and disclose medical information
to tell you about health-related benefits or services that
may be of interest to you.
- Fundraising Activities. We
may use demographic information about you to contact you
in an effort to raise money for the hospital and its
operations. We may disclose demographic information to a
foundation related to the hospital so that the foundation
may
contact you in raising money for the hospital. We only
release contact information, such as your name, address
and phone number and the dates you received treatment or
services at the
hospital. If you do not want the hospital to contact you
for fundraising efforts, you must notify HCHD Privacy
Officer in writing.
- Hospital Directory. We may
include certain limited information about you in the
hospital directory while you are a patient at the
hospital. This information may include your name, location
in the hospital, your general condition (e.g.,
undetermined, good, fair,
serious, and critical.) and your religious affiliation.
The directory information, except for your religious
affiliation, may also be released to people who ask for
you by name. Your religious affiliation may only be given
to a member of the clergy, such as a priest or rabbi, even
if they don’t ask for you by name. This is so your family,
friends and clergy can visit you in the hospital and
generally know how you are doing.
- Individuals Involved in
Your Care or Payment for Your Care. We may release medical
information about you to a friend or family member who is
involved in your medical care. We may also give
information to someone who helps pay for your care. We may
also tell your family or friends your condition and that
you are in the hospital. In addition, we may disclose
medical information about you to an entity assisting in a
disaster relief effort so that your family can be notified
about your condition, status and location.
- Research. Under certain
circumstances, we may use and disclose medical information
about you for research purposes. For example, a research
project may involve comparing the health and recovery of
all patients who received one medication to those who
received
another, for the same condition. All research projects,
however, are subject to a special approval process. This
process evaluates a proposed research project and its use
of medical information, trying to balance the research
needs with patients' need for privacy of their medical
information. Before we use or disclose medical information
for research, the project will have been approved through
this research approval process, but we may, however,
disclose medical information about you to people preparing
to conduct a research project, for example, to help them
look for patients with specific medical needs, so long as
the medical information they review does not leave the
hospital.
- As Required By Law. We
will disclose medical information about you when required
to do so by federal, state or local law.
- To Avert a Serious Threat
to Health or Safety. We may use and disclose medical
information about you when necessary to prevent a serious
threat to your health and safety or the health and safety
of the public or another person. Any disclosure, however,
would only be to someone able to help prevent the threat.
SPECIAL SITUATIONS
- Organ and Tissue
Donation. If you are an organ donor, we may release
medical information to organizations that handle organ
procurement or organ, eye or tissue transplantation or
to an organ donation bank, as necessary to facilitate
organ or tissue donation and transplantation.
- Military and Veterans.
If you are a member of the armed forces, we may release
medical information about you as required by military
command authorities. We may also release medical
information about foreign military personnel to the
appropriate foreign military authority.
- Workers' Compensation.
We may release medical information about you for
workers' compensation or similar programs. These
programs provide benefits for work-related injuries or
illness.
- Public Health Risks. We
may disclose medical information about you for public
health activities. These activities generally include
the following:
- To prevent or
control disease, injury or disability;
- To report births and
deaths;
- To report child
abuse or neglect;
- To report reactions
to medications or problems with products;
- To notify patients
of product recalls;
- To notify a person
who may have been exposed to a disease or may be at
risk for contracting or spreading a disease or
condition;
- To notify the
appropriate government authority if we believe a
patient has been the victim of abuse, neglect or
domestic violence. We will only make this disclosure
if you agree or when required or authorized by law.
- Health Oversight
Activities. We may disclose medical information to
a health oversight agency for activities
authorized by law. 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, and compliance
with civil rights laws.
- Lawsuits and
Disputes. If you are involved in a lawsuit or a
dispute, we may disclose medical information about
you in response to a court or administrative
order. We may also disclose medical information
about you in response to a subpoena, discovery
request, or other lawful process by someone else
involved in the dispute, but only if efforts have
been made to tell you about the request or to
obtain an order protecting the information
requested.
- Law Enforcement.
We may release medical information if asked to do
so by a law enforcement official:
- In response to
a court order, subpoena, warrant, summons or
similar process;
- To identify or
locate a suspect, fugitive, material witness,
or missing person;
- About the
victim of a crime if, under certain limited
circumstances, we are unable to obtain the
person's agreement;
- About a death
we believe may be the result of criminal
conduct;
- About criminal
conduct at the hospital; and
- In emergency
circumstances to report a crime; the location
of the crime or victims; or the identity,
description or location of the person who
committed the crime.
- Coroners,
Medical Examiners and Funeral Directors. We
may release medical information to a coroner
or medical examiner. This may be necessary,
for example, to identify a deceased person
or determine the cause of death. We may also
release medical
information about patients of the hospital
to funeral directors as necessary to carry
out their duties.
- National
Security and Intelligence Activities. We may
release medical information about you to
authorized federal officials for
intelligence, counterintelligence, and other
national security activities authorized by
law.
- Protective
Services for the President and Others. We
may disclose medical information about you
to authorized Federal officials so they may
provide protection to the President of the
United States, other authorized persons or
foreign heads of state or conduct special
investigations.
- Security
Clearances. We may use medical information
about you to make decisions regarding your
medical suitability for a security clearance
or service abroad. We may also release your
medical suitability determination to the
officials in the Department of State
who need access to that information for
these purposes.
- Inmates. If
you are an inmate of a correctional
institution or under the custody of a law
enforcement official, we may release medical
information about you to the correctional
institution or law enforcement official.
This release would be necessary (1) for the
institution to provide you with health care;
(2) to protect your health and safety or the
health and safety of others; or (3) for the
safety and security of the correctional
institution.
YOUR RIGHTS REGARDING MEDICAL INFORMATION
ABOUT YOU.
You have the following rights regarding medical information we maintain
about you:
- Right to
Inspect and Copy. You have the right to
inspect and request a copy of the
healthcare information that may be used to
make decisions about your care. Usually,
this includes medical and billing records,
but does not include psychotherapy notes.
To inspect and request a copy of healthcare
information that may be used to make decisions about you, you must submit
your request in writing to the Designated Record Custodian. 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,
you may request that the denial be
reviewed. A licensed health care
professional chosen by the hospital will
review your request and the denial. The
person conducting the review will not be
the person who denied your request. We
will comply with the outcome of the
review.
You may
contact the Record Custodian at:
Harris County Hospital District
Designated Record Custodian
2525 Holly Hall
Houston, TX 77054
Please indicate either attn: HIM for
Medical Records or Attn: PBS for Billing
Records
- 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 or
for the hospital.
To request an amendment, your request must
be made in writing and submitted on the Request for Amendment of the
Designated Record Set to the appropriate Designated Record Custodian. 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;
- Is not
part of the medical information kept
by or for the hospital;
- Is not
part of the information which you
would be permitted to inspect and
copy; or
- Is
accurate and complete.
If your request is denied you may submit a
“Statement of Disagreement” to the HCHD Privacy Officer.
You may contact the Record Custodian at:
Harris County Hospital District
Designated Record Custodian
2525 Holly Hall
Houston, TX 77054
Please indicate either attn: HIM for Medical Records or Attn: PBS for
Billing Records
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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 medical
information about you.
To request this list or accounting of
disclosures, you must submit your request in writing to the HCHD Privacy
Officer. Your request must state a time period, which may not be longer
than six years and may not include dates before April 14, 2003. Your
request should indicate in what form you want the list (e.g., on paper,
electronically). The first list you request within a 12-month period will
be free. For additional lists, we may charge you for the costs 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, like a
family member or friend. For
example, you could ask that we not
use or
disclose information about a
surgery you had.
We are not required to agree to your request. If we do agree, 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 HCHD
Privacy Officer. 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.
-
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, you
must make your request in writing to the HCHD Privacy Officer. We will not
ask you the reason for your request. We will accommodate all reasonable
requests. Your request must specify how or where you wish to be contacted.
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Right to a Paper Copy of This
Notice. You have the right to
a paper copy of this notice.
You may ask us to give you a
copy of this notice at any
time. Even if you have agreed
to receive this notice
electronically, you are still
entitled to a paper copy of
this notice.
You may obtain a copy of this notice at our
website, www.hchdonline.com
To obtain a paper copy of this notice:
Harris County Hospital District
Office of Privacy Administration
2525 Holly Hall
Houston, TX 77054
CHANGES TO THIS NOTICE
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We reserve the right to
change this notice. We
reserve the right to make
the revised or changed
notice effective for medical
information we already have
about you as well as any
information we receive in
the future. We will post a
copy of the current notice
in the hospital. The notice
will contain on the first
page, under the title, the
effective date. In addition,
each time you register at or
are admitted to the hospital
for treatment or health care
services as an inpatient or
outpatient, you may obtain a
copy of the current notice
in effect.
COMPLAINTS
If you believe your privacy
rights have been violated,
you may file a complaint
with the hospital or with
the Secretary of the U.S.
Department of Health and
Human Services. To file a
complaint with the hospital,
contact the Harris County
Hospital District’s Privacy
Officer at the address
and/or telephone number
listed below.
You will not be penalized
for filing a complaint.
OTHER USES OF MEDICAL
INFORMATION.
Other uses and disclosures
of medical information not
covered by this notice or
the laws that apply to us
will be made only with your
written permission. If you
provide us permission to use
or disclose medical
information about you, you
may revoke that permission,
in writing, at any time. If
you revoke your permission,
we will no longer use or
disclose
medical information about
you for the reasons covered
by your written
authorization. You
understand that we are
unable to take back any
disclosures we have already
made with your permission,
and that we are required to
retain our records of the
care that we provided to
you.
If you have any questions
about this notice, please
contact the HCHD Privacy
Officer at
Harris County Hospital
District
Office of Privacy
Administration
2525 Holly Hall
Houston, TX 77054
713-566-6097
hipaa@hchd.tmc.edu
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