|
Notice of Privacy Practices
For the Office of Kapusta Cosmetic
& Medical Vein Center, P.A./Vein Center Houston/Dr.
Mario O. Kapusta
This notice describes how medical
information about you may be used and disclosed and
how you can get access to this information. Please review
it carefully.
This practice uses and discloses health information
about you for treatment, to obtain payment for treatment,
for administrative purposes, and to evaluate the quality
of care that you receive. This notice describes our
privacy practices. You can request a copy of this notice
at any time. For more information about this notice
or our privacy practices and policies, please contact
the person listed on page 5 of this form.
Treatment, Payment, Health Care
Operations
Treatment
We are permitted to use and disclose your medical information
to those involved in your treatment. For example, your
care may require the involvement of another specialist.
When we refer you to a specialist, we will share some
or all of your medical information with that physician
to facilitate the delivery of care. In addition, the
physician in this practice is a specialist. When we
provide treatment, we may request that your primary
care physician share your medical information with us.
Also, we may provide your primary care physician information
about your particular condition so that he or she can
appropriately treat you for other medical conditions,
if any.
Payment
We are permitted to use and disclose your medical information
to bill and collect payment for the services provide
to you. For example, we may complete a claim form to
obtain payment from your insurer or HMO. The form will
contain medical information, such as a description of
the medical service provided to you, that your insurer
or HMO needs to approve payment to us.
Health Care Operations
We are permitted to use or disclose your medical information
for the purposes of health care operations, which are
activities that support this practice and ensure that
quality care is delivered. For example, we may engage
the services of a professional to aid this practice
in its compliance programs. This person will review
billing and medical files to ensure we maintain our
compliance with regulations and the law, so that we
may ensure that only the best health care is provided
by this practice. We may also ask another physician
to review this practice’s charts and medical records
to evaluate our performance so that we may ensure that
only the best health care is provided y this practice.
Disclosures That Can Be Made Without
Your Authorization
There are situations in which we are permitted by law
to disclose or use your medical information without
your written authorization or an opportunity to object.
In other situations we will ask for your written authorization
before using or disclosing any identifiable health information
about you. If you choose to sign an authorization to
disclose information, you can later revoke that authorization,
in writing, to stop future uses and disclosures. However,
any revocation will not apply to disclosures or uses
already made or taken in reliance on that authorization.
Public Health, Abuse or Neglect,
and Health Oversight
We may disclose your medical information for public
health activities. Public health activities are mandated
by federal, state, or local government for the collection
of information about disease, vital statistics (like
births and deaths), or injury by a public health authority.
We may disclose medical information, if authorized by
law, to a person who may have been exposed to a disease
or may be at risk for contracting or spreading a disease
or condition. We may disclose your medical information
to report reactions to medications, problems with products,
or to notify people of recalls of products they may
be using.
We may also disclose medical information to a public
agency authorized to receive reports of child abuse
or neglect. Texas law requires physicians to report
child abuse or neglect. Regulations also permit the
disclosure of information to report abuse or neglect
of elders or the disabled.
We may disclose your medical information to a health
oversight agency for those activities authorized by
law. Examples of these activities are audits, investigations,
licensure applications and inspections which are all
government activities undertaken to monitor the health
care delivery system and compliance with other laws,
such as civil rights laws.
Legal Proceedings and Law Enforcement
We may disclose your medical information in the course
of judicial or administrative proceedings in response
to an order of the court (or the administrative decision-maker)
or other appropriate legal process. Certain requirements
must be met before the information is disclosed.
If asked by a law enforcement official, we may disclose
your medical information under limited circumstances
provided that the information:
•Is released pursuant to legal process, such as
a warrant or subpoena;
•Pertains to a victim of crime and your are incapacitated;
•Pertains to a person who has died under circumstances
that may be related to criminal conduct;
•Is about a victim of crime and we are unable to
obtain the person’s agreement;
•Is released because of a crime that has occurred
on these premises; or
•Is released to locate a fugitive, missing person,
or suspect.
We may also release information if we believe the disclosure
is necessary to prevent or lessen an imminent threat
to the health or safety of a person.
Workers’ Compensation
We may disclose your medical information as required
by the Texas workers’ compensation law.
Inmates
If you are an inmate or under the custody of law enforcement,
we may release your medical information to the correctional
institution or law enforcement official. This release
is permitted to allow the institution to provide you
with medical care, to protect your health or the health
and safety of others, or for the safety and security
of the institution.
Military, National Security
and Intelligence Activities, Protection of the President
We may disclose your medical information for specialized
governmental functions such as separation or discharge
from military service, requests as necessary by appropriate
military command officers (if you are in the military),
authorized national security and intelligence activities,
as well as authorized activities for the provision of
protective services for the President of the United
States, other authorized government officials, or foreign
heads of state.
Research, Organ Donation, Coroners, Medical Examiners,
and Funeral Directors
When a research project and its privacy protections
have been approved by an Institutional Review Board
or privacy board, we may release medical information
to researchers for research purposes. We may release
medical information to organ procurement organizations
for the purpose of facilitating organ, eye, or tissue
donation if you are a donor. Also, we may release your
medical information to a coroner or medical examiner
to identify a deceased or a cause of death. Further,
we may release your medical information to a funeral
director where such a disclosure is necessary for the
director to carry out his duties.
Required by Law
We may release your medical information where the disclosure
is required by law.
Your Rights Under Federal Privacy
Regulations
The United States Department of Health and Human Services
created regulations intended to protect patient privacy
as required by the Health Insurance Portability and
Accountability Act (HIPAA). Those regulations create
several privileges that patients may exercise. We will
not retaliate against a patient that exercises their
HIPAA rights.
Requested Restrictions
You may request that we restrict or limit how your protected
health information is used or disclosed for treatment,
payment, or healthcare operations. We do NOT have to
agree to this restriction, but if we do agree, we will
comply with your request except under emergency circumstances.
To request a restriction, submit the following in writing:
(a) The information to be restricted, (b) what kind
of restriction you are requesting (i.e. on the use of
information, disclosure of information or both), and
(c) to whom the limits apply. Please send the request
to the address and person listed below.
You may also request that we limit disclosure to family
members, other relatives, or close personal friends
that may or may not be involved in your care.
Receiving Confidential Communications by Alternative
Means
You may request that we send communications of protected
health information by alternative means or to an alternative
location. This request must be made in writing to the
person listed below. We are required to accommodate
only reasonable requests. Please specify in your correspondence
exactly how you want us to communicate with you and,
if you are directing us to send it to a particular place,
the contact/address information
.Inspection and Copies of Protected
Health Information
You may inspect and/or copy health information that
is within the designated record set, which is information
that is used to make decisions about your care. Texas
law requires that requests for copies be made in writing
and we ask that requests for inspection of your health
information also be made in writing. Please send your
request to the person listed below. There will be a
$45.00 administrative fee.
We can refuse to provide some of the information you
ask to inspect or ask to be copied if the information:
•Includes psychotherapy notes.
•Includes the identity of a person who provided
information if it was obtained under a promise of confidentiality.
•Is subject to the Clinical Laboratory Improvements
Amendments of 1988.
•Has been compiled in anticipation of litigation.
We can refuse to provide access to or copies of some
information for other reasons, provided that we provide
a review of our decision on your request. Another licensed
health care provider who was not involved in the prior
decision to deny access will make any such review.
Texas law requires that we are ready to provide copies
or a narrative within 15 days of your request. We will
inform you of when the records are ready or if we believe
access should be limited. If we deny access, we will
inform you in writing.
HIPAA permits us to charge a reasonable cost based fee.
The Texas State Board of Medical Examiners (TSBME) has
set limits on fees for copies of medical records that
under some circumstances may be lower than the charges
permitted by HIPAA. In any event, the lower of the fee
permitted by HIPAA or the fee permitted by the TSBME
will be charged.
Amendment of Medical Information
You may request an amendment of your medical information
in the designated record set. Any such request must
be made in writing to the person listed below. We will
respond within 60 days of your request. We may refuse
to allow an amendment if the information:
•Wasn’t created by this practice or the physicians
here in this practice.
•Is not part of the Designated Record Set?
• Is not available for inspection because of an
appropriate denial.
•If the information is accurate and complete.
Even if we refuse to allow an amendment you are permitted
to include a patient statement about the information
at issue in your medical record. If we refuse to allow
an amendment we will inform you in writing. If we approve
the amendment, we will inform you in writing, allow
the amendment to be made and tell others that we know
have the incorrect information.
Accounting of Certain Disclosures
The HIPAA privacy regulations permit you to request,
and us to provide, an accounting of disclosures that
are other than for treatment, payment, health care operations,
or made via an authorization signed by you or your representative.
Please submit any request for an accounting to the person
listed below. Your first accounting of disclosures (within
a 12 month period) will be free. For additional requests
within that period we are permitted to charge for the
cost of providing the list. If there is a charge we
will notify you and you may choose to withdraw or modify
your request before any costs are incurred.
Appointment Reminders, Treatment
Alternatives, and Other Health-related Benefits
We may contact you by telephone, mail, or both to provide
appointment reminders, information about treatment alternatives,
or other health-related benefits and services that may
be of interest to you. You must notify us in writing
if you do not wish to have messages left on your telephone
answering devices.
Complaints
If you are concerned that your privacy rights have been
violated, you may contact the person listed below. You
may also send a written complaint to the United States
Department of Health and Human Services. We will not
retaliate against you for filing a complaint with the
government or us. The contact information for the United
States Department of Health and Human Services is:
U.S. Department of Health and Human Services
HIPAA Complaint
7500 Security Blvd., C5-24-04
Baltimore, MD 21244
Our Promise to You
We are required by law and regulation to protect the
privacy of your medical information, to provide you
with this notice of our privacy practices with respect
to protected health information, and to abide by the
terms of the notice of privacy practices in effect.
Questions and Contact Person
for Requests
If you have any questions or want to make a request
pursuant to the rights described above, please contact:
Rachel Enriquez, Privacy Officer
PO Box 6730
Houston, TX 77265
Phone Number (713) 349-8346, Fax (713) 218-8346
This notice is effective on the following date: April
14, 2003.
We may change our policies and this notice at any time
and have those revised policies apply to all the protected
health information we maintain. If or when we change
our notice, we will post the new notice in the office
where it can be seen.
|
