1. health and fitness

PATIENT RIGHTS
& PATIENT RESPONSIBILITY
EVERY PATIENT SHALL HAVE THE RIGHT TO:
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Reasonable access to care
Receive considerate and respectful care
Visitors
Know the name of his/her physician
Knowledge concerning the professional status of caregivers
Know the reasons for any proposed change in the professional staff responsible for his/her care
Know the relationship(s) of the hospital to other persons or organizations participating in the provision of his/her care
Be informed of his/her health condition, including unanticipated outcomes
Information concerning: diagnosis, treatment, & prognosis
Have patients family be informed of consent of donation or organs and tissues
Be involved in care planning and treatment
Formulate advance directives and appoint a surrogate to make healthcare decisions on his/her behalf to the extent permitted by law;
have the hospital staff and practitioners comply with those directive including withholding resuscitative services, forgoing or
withdrawal of life sustaining treatment
Have a family member or representative of choice and his/her own physician notified promptly of admission to the hospital
Accept or refuse treatment and be informed of the medical consequences of such refusal
Make informed decisions regarding participation in clinical research
Personal respect, privacy, and confidentiality
Access to information contained in his/her clinical or medical records within a reasonable time frame.
Confidentiality of clinical and medical records
Social, religious, and psychological well being
Reasonable response to requests for service including ethical issues
A qualified interpreter if needed
Be informed of hospital rules, regulations, and complaint resolution
Be informed of the reason for transfer to another facility
Access protective services
Appropriate assessment and management of pain
The right to be free from restraints or seclusion that are not medically necessary or used as a means of coercion, discipline, staff
convenience, or retaliation
Receive care in a safe setting and be free from abuse or harassment
Access to the cost, itemized when possible, of services rendered within reasonable period of time
Be informed of the source of the hospitals reimbursement for his/her services, and of any limitations which may be placed upon
his/her care
EVERY PATIENT IS RESPONSIBLE FOR:
Communicating honestly and directly
Cooperating with healthcare team
Understanding his/her health issues
Participating in his/her medical plan
Consequences resulting from non-compliance
Following hospital rules and regulations
Being respectful of others and hospital property
Informing the hospital of a violation of patient rights
Fulfilling his/her financial obligations for healthcare
Communicating any safety concerns including perceived risks in his/her care, and unexpected change(s) in his/her condition
COMPLAINTS AND GRIEVANCES:
If you have a concern regarding any aspect of your care, please contact the Department of State Health Services (DSHS) 888-9730011 or write to Health Facility Licensing and Compliance Complaints, Department of State Health Services (DSHS), 1100 West
49th Street, Austin, Texas 75756-3199. You may also contact us at Texas General Hospital at (469) 999-0000 during regular business
hours (9:00am to 5:00pm, Monday through Friday, excluding holidays) and ask for Administration or at
[email protected].
OUR MISSION
The mission of Texas General Hospital is to bring state of the art health and welfare to the community.
• 2709 HOSPITAL BLVD •GRAND PRAIRIE, TX 75051•PH 469-999-0000
Conditions of Admission and Authorization for
Medical Treatment
1.
Consent to treatment. I consent to the procedures which may be performed during this hospitalization or on an outpatient basis,
including emergency treatment or services, and which may include but are not limited to laboratory procedures, x-ray examination,
diagnostic procedures, medical, nursing or surgical treatment procedure, anesthesia, or hospital services, rendered to me as ordered
by my physician or other healthcare professional on the hospital medical staff. I understand that as part of their training, student in
healthcare education may participate in the delivery of my medical care and treatment or be observers while I received medical care
and treatment at the hospital, and that there student will be supervised by qualified instructors and hospital staff.
2.
Financial Agreement. In consideration of the services to be rendered to the patient, I, individually, promise to pay the patients
account at the rates stated in the hospital price list (known as the “charge master”) effective on the date the charge processed for the
services provided, which rates are hereby expressly incorporate by reference as the price tem of this agreement to pay the patients
account. Some special items will be priced separately if there is no price listed in the charge master, or if the charge is listed as zero/
an estimate of the anticipated charges for services to be provided to the patient is available upon request form the hospital. Estimates
may vary significantly from the final charges based on a variety of factors, including but not limited to, the course of treatment,
intensity of care, physician practices, and the necessity of providing additional goods and services.
If supplies and services are provided to a patient who has coverage through a government program or certain private health insurance
plans, the hospital may accept a discounted payment for those supplies and services. In this even, any payment required from the
undersigned will be determined by the terms of the governmental program or private health insurance plan. If the patient is uninsured
and not cover by any governmental program, the patient may be eligible to have his/her account discounted or forgiven under the
hospital’s uninsured discount or charity care programs in effected at the time of the treatment. You may request information about
these programs form the hospital.
As courtesy to you, the hospital may bill your insurance company, but is not obligated to do so. Regardless, you agree that except
where prohibited by law, the financial responsibilities for the services rendered belong to you the undersigned.
The hospital will provide a medical screening examination as required to all patients who are seeking medical services, to determine
if there is an emergency medical condition, without regard to the patient’s ability to pay. If there is an emergent medical condition,
the hospital will provide stabilizing treatment within its capacity. However, the patients who do not qualify under the hospital charity
care policy or other applicable policy or other applicable policy are not relieved of their obligation to pay for these services.
3.
Assignment of Benefits. In executing this assignment if benefits, I am directing the health insurance carrier or health benefit plan
providing my coverage (including, but not limited to any employer, employer group or trust sponsored or offered plan) to pay the
hospital and /or hospital-based physicians directly for the services the hospital and/or hospital based physicians provided to the
patient during this admission. In return for the services rendered and to be entered by the hospital and/or the hospital base physicians,
I hereby irrevocably assign and transfer to the hospital and / or hospital based physician, all right, title, and interest in all benefits
payable for the healthcare rendered, which are provided in any and all insurance policies and health benefit plans form which I am
entitled services or I am entitle to recover. I understand that any payment received form these policies and/or plans will be apply to
the amount that I have agreed to pay for services rendered during this admission. This assignment shall be for the purpose of granting
the hospital and/or hospital based physicians, and independent right of recovery against my insurer or health benefit plan, but shall
not be construed as an obligation of the hospital and/or hospital based physicians to pursue any such right of recovery. In no event
will the hospital and/or hospital based physicians retain benefits in excess of the amount owed to the hospital and/or hospital based
physicians for the care and treatment rendered during the admission. If a third party payer (such as an insurance company or
employer group or trust sponsored or offered plan) may be obligated to pay some or all of these charges, I agree to take all actions
necessary to assist the hospital and/or hospital base physicians in collecting payment form any such third party payer. I hereby
appoint the hospital as my authorized representative to pursue, if it so chooses, all administrative remedies, claims and/or lawsuits on
my behalf and at the hospital’s election, again any responsible third party, medical insurer, or employer sponsored medical benefit
plan for purposed of collection any and all hospital benefits due to me for the payment of the charges referred to in Section 2 above.
If the hospital elects to pursue a claim or lawsuit against a third party payer as authorized representative, I agree to execute a special
power of attorney , if requested , authorizing the hospital to take all actions necessary or appropriate in pursuit of such claim or
lawsuit, including allowing the hospital to bring suit against the third party in my name. I agree to pay over the hospital, immediately,
all the sum recovered in any claim or lawsuit brought on my behalf by the hospital (up to the amount of the hospital’s charges, plus
expenses and attorney’s fees). I have read and been given the opportunity to ask questions about this assignment of benefits, and I
have signed this document freely and without inducement, other than the rendition of services by the hospital and/or hospital based
physicians.
• 2709 HOSPITAL BLVD •GRAND PRAIRIE, TX 75051•PH 469-999-0000
4.
Medicare Patient Certification and assignment of Benefits. I certify that any information I provide in applying for payment under
Title XVIII (Medicare) or Title XIX (Medicaid) of the Social Security Act is correct. I request payment of authorized benefits to be
made on my behalf to the Hospital and/or hospital based physician by the Medicare or Medicaid program.
Other acknowledgments
5.
Legal Relationship between Hospital and Physician. Most or all of the healthcare professional performing services in the hospital
are independent contractors and are not hospital agent or employees. Independent contractors are responsible for their own actions
and the hospital shall not be liable for the acts or omissions of any such independent contractors. I understand that physicians or other
healthcare professionals may be called upon to provide care or services to me or on my behalf, but that I may not actually see, or be
examined by, all physicians or healthcare professionals’ participating in my care; for example, I may not see physicians providing
radiology, pathology, EKG interpretation and/or anesthesiology service. I understand that, in most instances there will be a separate
charge for professional service rendered by physicians to me or on my behalf, and that I will receive a bill for these professional
services that is separate form the bill for hospital services.
6.
Personal Valuables. I understand that the hospital advises that all personal property should be left at home or given to a designee for
safe keeping. I understand that the hospital maintains a safe for the safekeeping of money and valuables in the event personal
property cannot be sent home. The hospital shall not be liable for the loss of damage to any money, dentures, jewelry, documents,
furs, fur coat and garments, or other articles of unusual value and small size, unless placed in the safe and shall not be liable for the
lost or damages to any other personal property, unless deposited with the hospital for safekeeping. The liability of the hospital for
loss of any personal property that is deposited with the hospital for safekeeping is limited to the lesser of five hundred dollars
($500.00) or the maximum required by the law, unless a written receipt for a greater amount has been obtained from the hospital by
the patient.
7.
Weapons/explosives/drugs. I understand and agree that if the hospital, at any time, believes there may be a weapon, explosive
device, illegal substance or drug, or any alcoholic beverage in my room or with my belongings, the hospital may search my room and
my belongings, confiscate any of the above items that are found, and dispose of them as appropriate, including delivery of any item
to law enforcement authorities.
8.
Hospital Complain / Grievance Process. At Texas General Hospital, we strive to deliver quality and cost effective care to the
patients serve. However, if at any time you feel that we have not satisfactorily met your needs and/ or you have concerns about the
care or service we proved. Please let us know immediately. We want to assure you that the presentation of a complaint will not serve
to compromise your care. We have a grievance policy that we enforce. I acknowledge that I have received information about
Hospital’s patient complaint/grievance process.
NOTICE TO PATIENTS REGARDING YOUR RIGHT TO MAKE
ADVANCED HEALTH CARE DECISION
Federal Law requires that we give you information about your right to make advanced health care decisions. Right now, you may be able to
make such decisions, however you may not always have the ability to make such decisions. By giving advanced instructions, l you can tell
your doctor and family about the medical care you would like to receive and whether you want another person to be able to accept or rescue
treatment for you, just in case you are unable to make such decisions yourself.
You can name a person to make medical treatment decisions for you by naming someone a “durable Power of Attorney for Health Care” for
you. This person is allowed to make health care decisions for you, but only after your doctor believes that you are no longer able to make your
own health care decisions.
You can also leave advanced instructions about life support. This is often called a “Living Will”. A “Living Will” tells your doctor and family
about the types of life support that you want to be provided or withheld in case you are ever kept alive by artificial means and no longer able
to make decisions for yourself.
If you already have a “Living Will” or a “Durable Power of Attorney for Health Care”, please tell your doctor and this hospital. We need to
put a copy of the document in your medical chart in order to be sure that your wishes are honored. If you want more information on how to
name a “Durable Power of Attorney for Health Care” or how to make a “Living Will” please feel free to ask either your doctor or your
attorney. A blank “Living Will” or “Durable Power of Attorney for Health Care” is available to you upon request.
It is the policy of this hospital to honor a patients’ health care decision to the full extent required or allowed by law. You are not required to
give advanced health care instructions in order to receive care at this hospital.
• 2709 HOSPITAL BLVD •GRAND PRAIRIE, TX 75051•PH 469-999-0000
Patient Self- Determination Act
Definition
“Advance Directive” Means:
A. A directive, as that term is defined by section 166.031;
B. An out-of-hospital DNR order or
C. A medical power of attorney under subchapter D.
“Artificial nutrition and hydration” means the provision of nutrients or fluids by a tube inserted in a vein, under the skin in the subcutaneous tissue, or in the
stomach (gastrointestinal tract).
“Attending physician” means a physician selected by or assigned to a patient who has primary responsibility for a patient’s treatment and care.
“Competent” means possessing the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment
decision, including the significant benefits and harms of and reasonable alternatives to a prosed treatment decision.
“Declarant” means a person who has executed or issued a directive under this chapter.
“Digital signature” means an electronic identifier intended by the person using it to have the same force and effect as the use of a manual signature.
“Electronic signature” means a facsimile, scan, uploaded image, computer-generated image, or other electronic representation of a manual signature that is
intended by the person using it to have the same force and effect of law as a manual signature.
“Ethics or Medical committee” means a committee
“Health Care or Treatment decision” means consent, refusal to consent, or withdrawal of consent to health care, treatment, service, or a procedure to maintain,
diagnose, or treat an individual’s physical or mental condition, including such a decision on behalf of a minor.
“Incompetent” means lacking the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment
decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision.
“Irreversible condition: means a condition, injury, or illness:
A. That may be treated but is never cured or eliminated:
B. That leaves a person unable to care for or make decisions for the person’s own self;
And
C. That, without life-sustaining treatment provided in accordance with the prevailing standard of medical care, is fatal.
“Life-sustaining treatment” means treatment that, based on reasonable medical judgment, sustains the life of a patient and without which the patient will die.
The term includes both life-sustaining medications and artificial life support, such as mechanical breathing machines, kidney dialysis treatment, and artificial
nutrition and hydration. The rem does not include the administration of pain management medication or the performance of a medical procedure considered to
be necessary to provide comfort care, or any other medical care provided to alleviate a patient’s pain.
“Medical Power of Attorney” means a document delegating to an agent authority to make health care decisions execute or issued under Subchapter D.
“Physician” Means:
a) A physician licensed by the Texas State Board of Medical Examiners; or
b) A properly credentialed physician who holds a commission in the uniformed services of the United States and who is serving on active duty in this
state.
“Terminal condition” means an incurable condition caused by injury, disease, or illness that according to reasonable medical judgment will produce death
within six months, even with available life-sustaining treatment provided in accordance with the prevailing standard of medical care. A patient who has been
admitted to a program under which the person receives hospice services provided by a home and/or a community support services agency.
“Witness” means a person who may serve as a witness.
“Cardiopulmonary resuscitation” means any medical intervention used to restore circulatory or respiratory function that has ceased.
• 2709 HOSPITAL BLVD •GRAND PRAIRIE, TX 75051•PH 469-999-0000
Patient Self- Determination Act
To the extent allowed by law, it is our policy to follow the directions with respect to medical care at Texas General Hospital of our patients who have
the capacity to make decisions.
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You will be considered to have the capacity to make health care decisions unless unconscious, determined to be incompetent by a court of law or
determined medically unable by your attending physician.
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Before any non-emergency medical treatment is performed, you have a right to receive form your physician whatever information you need to give
your informed consent. The information provided to you should answer your questions about the intended procedure or treatment, the potential risks
associated with the treatment, and alternative treatment and their risks. Your will be asked to sign a form verifying you have given your physician
your consent to perform the procedure.
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If you refuse treatment, you will be informed by your physician of significant medical consequences that may result from this refusal, and you may
be asked to sign a form about your refusal.
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If you are unable to make decisions, but have signed a valid advance directive, we will follow your directive to the extent allowed under Texas law.
No life-sustaining treatment may be removed during pregnancy.
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If you are unable to take sufficient food and water by mouth to keep you alive and are without capacity to make health care decisions, Texas law
considers that you have directed that tube feedings be administered, unless:
o You have an advance directive specifying the withholding or withdrawals of feedings and our are in condition defined in your directive;
o Your physician clearly knows or a court finds that when competent and with information necessary to make such a decision, your decided
that tube feedings should be withheld or withdrawn;
o The tube feedings themselves would cause your severe, intractable and long-lasting pain;
o Tube feedings are not medically possible; or
o You are chronically and irreversibly and in the final stages of terminal illness or injury in which death is imminent and death will not be
caused by dehydration or starvation.
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Similarly, if you are without capacity to make health care decisions, you will be considered to have directed other life-sustaining treatment be given,
unless;
o You have a valid advance directive and are determined to be in a condition which qualifies you to have treatment withheld; or
o The treatments are considered medically inappropriate or futile; or
o All family members agree that the proposed treatment is not what you would want and your family members have signed a Family
Verification to that effect.
If you have any question regarding our policies, please talk to your physician or nurse.
• 2709 HOSPITAL BLVD •GRAND PRAIRIE, TX 75051•PH 469-999-0000
Texas General Hospital
Notice of Privacy Practices
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 Officer at
469-999-0166
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
demographic information, that may identify you and that relates
to your past, present or future physical or mental health or
condition and related health care services.
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.
1.
How we may use and disclose your medical information
Uses and Disclosures of Protected Health Information Based Upon Your
Written Consent
You will be asked by your physician to sign a consent form.
Once you have consented to use and disclosure of your protected
health information for treatment, payment and health care
operations by signing the consent form, your physician will use
or disclose your protected health information as described in this
Section 1. Your protected health information may be used and
disclosed by your physician, our office staff and others outside of
our office that are involved in your care and treatment for the
purpose of providing health care services to you. Your protected
health information may also be used and disclosed to pay your
health care bills and to support the operation of the physician’s
practice.
Following are examples of the types of uses and disclosures of
your protected health care information that the physician’s office
is permitted to make once you have signed our consent form.
These examples are not meant to be exhaustive, but to describe
the types of uses and disclosures that may be made by our office
once you have provided consent.
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 that has
already obtained your permission to have access to your
protected health information. For example, we would disclose
your protected health information, as necessary, to a home health
agency that provides care to you. We will also disclose protected
health information to other physicians who may be treating you
when we have the necessary permission from you to disclose
your protected health information. For example, your protected
health information may be provided to a physician to whom you
have been referred to ensure that the physician has the necessary
information to diagnose or treat you.
In addition, we may disclose your protected health information
from time-to-time 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 by providing assistance
with your health care diagnosis or treatment to your physician.
Payment: Your protected health information will be used, as
needed, to obtain payment for your health care services. This may
include certain activities that your health insurance plan may
undertake before it approves or pays for the health care services
we recommend for you such as; making a determination of
eligibility or coverage for insurance benefits, reviewing services
provided to you for medical necessity, and undertaking utilization
review activities. For example, obtaining approval for a hospital
stay may require that your relevant protected health information
be disclosed to the health plan to obtain approval for the hospital
admission.
Healthcare 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 disclose your protected health information
to medical school students that see patients at our office. In
addition, we may use a sign-in sheet at the registration desk
where you will be asked to sign your name and indicate your
physician. We may also call you by name in the waiting room
when your physician is ready to see you. We may use or disclose
your protected health information, as necessary, to contact you to
remind you of your appointment.
We will share your protected health information with third party
“business associates” that perform various activities (e.g., billing,
and 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.
We may use or disclose your protected health information, as
necessary, to provide you with information about treatment
alternatives or other health-related benefits and services that may
be of interest to you. We may also use and disclose your
protected health information for other marketing activities. For
example, your name and address may be used to send you a
newsletter about our practice and the services we offer. We may
also send you information about products or services that we
believe may be beneficial to you. The sale of your protected
health information and the use of such information for paid
marketing require authorization from you. Other uses and
disclosures not described in this Notice, will be made only with
authorization
You may contact our Privacy Officer to request that these
materials not be sent to you.
We may use or disclose your demographic information and the
dates that you received treatment from your physician, as
necessary, in order to contact you for fundraising activities
supported by our office. If you do not want to receive these
materials, please contact our Privacy Officer and request that
these fundraising materials not be sent to you.
Uses and Disclosures of Protected Health Information Based upon Your
Written Authorization
Other uses and disclosures of your protected health information
will be made only with your written authorization, unless
otherwise permitted or required by law as described below. 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 Object
We 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
• 2709 HOSPITAL BLVD •GRAND PRAIRIE, TX 75051•PH 469-999-0000
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.
Facility Directories: Unless you object, we will use and disclose
in our facility directory your name, the location at which you are
receiving care, your condition (in general terms), and your
religious affiliation. All of this information, except religious
affiliation, will be disclosed to people that ask for you by name.
Members of the clergy will be told your religious affiliation.
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.
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
Others Involved in Your Healthcare: 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 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.
Other Permitted and Required Uses and Disclosures That May Be Made Without
Your Consent, Authorization or Opportunity to Object
We 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 for public health activities and purposes to a public
health authority that is permitted by law to collect or receive the
information. The disclosure will be made for the purpose of
controlling disease, injury or disability. We may also disclose
your protected health information, if directed by the public health
authority, to a foreign government agency that is collaborating
with the public health authority.
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 a health oversight agency for activities authorized
by law, such as audits, investigations, and inspections. Oversight
agencies seeking this information include government agencies
that oversee the health care system, government benefit
programs, other government regulatory programs and civil rights
laws.
Abuse or Neglect: We may disclose your protected health
information to a public health authority that is authorized by law
to receive reports of child abuse or neglect. In addition, we may
disclose your protected health information if we believe that you
have been a victim of abuse, neglect or domestic violence to the
governmental entity or agency authorized to receive such
information. 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 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.
Coroners, Funeral Directors, and Organ Donation: We may
disclose protected health information to a coroner or medical
examiner for identification purposes, determining cause of death
or for the coroner or medical examiner to perform other duties
authorized by law. We may also disclose protected health
information to a funeral director, as authorized by law, in order to
permit the funeral director to carry out their duties. We may
disclose such information in reasonable anticipation of death.
Protected health information may be used and disclosed for
cadaver organ, eye or tissue donation purposes.
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.
Criminal Activity: 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. We may also disclose protected health information
if it is necessary for law enforcement authorities to identify or
apprehend an individual.
• 2709 HOSPITAL BLVD •GRAND PRAIRIE, TX 75051•PH 469-999-0000
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: We may disclose your protected
health information as authorized to comply with workers’
compensation laws and other similar legally established
programs.
Inmates: We may use or disclose your protected health
information if you are an inmate of a correctional facility and
your physician created or received your protected health
information in the course of providing care to you.
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 Section
164.500 et. seq.
2. Your Rights
Following 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
your protected health information 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 uses for making decisions about you.
Under federal law, however, you may not inspect or copy the
following records; psychotherapy notes; information compiled in
reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding, and protected health
information that is subject to law that prohibits access to
protected health information. Depending on the circumstances, a
decision to deny access may be reviewable. In some
circumstances, you may have a right to have this decision
reviewed. Please contact our Privacy Officer if you have
questions about access to your medical record.
You have the right to request a restriction of your protected
health information. This means you may ask us not to use or
disclose any part of your protected health information for the
purposes of treatment, payment or healthcare operations. 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
writing a written request to the Director of Medical Records. 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.
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 Officer.
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.
In certain cases, we may deny your request for an amendment. 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 Officer 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, for a facility directory, 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 the right to obtain a paper copy of this notice from
us, upon request, even if you have agreed to accept this notice
electronically.
You have the right to be notified of breaches of Protected
Health Information.
You have the right to restrict disclosures to your health plan
for services for which you pay out of pocket.
3. Complaints
You may complain to us or to the Secretary of Health and Human
Services if you believe we have violated your privacy rights by
us. You may file a complaint with us by notifying our privacy
contact of your complaint. We will not retaliate against you for
filing a complaint.
You may contact our Privacy Officer, Sedonia Grant, Medical
Record Director at 469-999-0166 for further information about
the complaint process.
This notice was published and becomes effective on
March 1, 2013..
• 2709 HOSPITAL BLVD •GRAND PRAIRIE, TX 75051•PH 469-999-0000