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.
To appropriately treat you and receive payment for the services we provide, we need to obtain information from you including your full name and address, insurance company, family medical history, current medical history, and current medical condition. We will use and disclose this information and other information we collect in the ways generally described below. To help you understand how we will use and disclose your information we have put the different uses and disclosures into categories and give examples of each. All of the ways we use or disclose your information will fit into one of the categories listed below, but we cannot list al of the uses and disclosures in each category.
We may use and disclose your health information for treatment, payment, and health care operations.
- Treatment: We may use and disclose your information to provide you with medical treatment and services. Your information may be disclosed to individuals providing care to you and different departments in this facility. These individuals and departments need your information to provide care, and to coordinate and provide services (such as prescriptions, lab tests, and x-rays). We may also disclose your information to individuals or entities other than this facility that may be involved in your care such as your primary physician, consulting technicians or physicians, or emergency department physicians.
- Payment: We may use and disclose your information to receive payment for the services and treatment provided to you. We use your information to create a bill and disclose your information when we send the bill to your insurance company, you, or third party paying for your care or treatment. The individual or entity paying the bill may request more information to determine whether the bill is covered by your insurance. We may tell your health plan about a treatment you are going to receive to get approval for payment or to determine whether your health plan will cover the treatment. We may disclose your information to another healthcare provider so it can receive payment for services provided to you. We may also disclose your information to a collection agency or to a consumer credit reporting agency.
- Health Care Operations: We may use and disclose your information for health care operation purposes. Health care operations include review of the care you receive for quality assessment, educational, business planning, and compliance plan purposes.
We may disclose and use your health information for:
- Appointment Reminders: We may provide appointment reminders to you. You may request ni writing that we send to a confidential or alternative address.
- Treatment Alternatives: We may provide you with information about treatment alternatives and other health related benefits and services.
We may also disclose your health information to outside entities without your authorization ni the following circumstances:
- Required by Law: We disclose information as required by law. For example, we are required to report gunshot wounds to the police.
- Public Health Purposes: We disclose information the health agencies as required by law. Examples are reporting of sexually transmitted, communicable, and infectious diseases.
- Employer: We disclose information to your employer about work-related illness or injury as required by law.
- To Prevent a Serious Threat to Health of Safety: We may disclose information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.
- Research: Your information may be used by or disclosed to researchers for research approved by a privacy board or an institutional review board.
- Health Oversight Activities: Your health information may be disclosed to governmental agencies and boards for investigations, audits, licensing, and compliance purposes.
- Judicial and Administrative Proceedings: We may be required to disclose your health information to a court or for an administrative proceeding.
- Law Enforcement Activities: We may be required to disclose your information as required by law, pursuant to a court order, warrant, subpoena, or summons, or if you are the Victim of a crime.
- In Emergency Circumstances
- Deceased Individual: We may disclose information for the identification of the body, to determine the cause of death or to alert law enforcement of your death.
- Military and Veterans: If you are a member of the armed forces, we may release information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.
- Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your information to the correctional institution or law enforcement official.
- Protective Services for the President and Others
- Organ and Tissue Donation: If you are an organ donor, we may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ bank, as necessary to facilitate organ and tissue donation.
- Workers Compensation: We may release medical information about you for workers compensation or similar programs. National Security and Intelligence Activities: We may release information about you to authorized Federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
We will give you the opportunity to object to the following uses and disclosures of your information:
- Notification: We may tell your friends, relatives, and other caretakers information about your location, your general condition, or notification of death.
- Communication with Family: We may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do n o t object or in an emergency.
- Disaster Relief: We may disclose information about you to public or private agencies for disaster relief purposes.
Your Rights
- You have the right to request a restriction on how information about you is used and disclosed. We are not required to agree to any restriction on the use or disclosure of your information.
- You have the right to request communications with you be made at an alternative address or phone number.
- You have the right to inspect and copy your medical records.
- If you believe the information we have about you is incorrect or incomplete you may request that we amend your medical record.
- You have the right to receive an accounting of disclosures, a list of individuals and entities that received your health information for reasons other than treatment, payment, healthcare operations. In general, you do not have a right to an accounting if we are authorized by law to release your information without your prior authorization or if you authorize release of your information.
- You have the right to request a paper copy of this Notice.
- To make any of the above requests, contact the Office Manager of Amarillo Urgent Care at (806) 352-5400.
Our Duties
- We are required by law to maintain the privacy of protected health information and to provide individuals with this Notice of our legal duties and privacy practice regarding health information.
- We are required to follow the terms of the current Notice.
- Uses and disclosures of your health information not permitted by law will require your written authorization. You may revoke any such authorization unless we have already acted in reliance on your authorization.
- We may change the terms of this Notice and the revised Notice will apply to all health information in our possession. If we revise this Notice, a copy of the revised Notice will be posted at Amarillo Urgent Care and a copy may be requested from the Office Manager.
Information Complaints
If you have questions about this notice, want more information, or if you believe your privacy rights have been violated you may contact: the Office Manager of Amarillo Urgent Care at (806) 352-5400, the Secretary of The Department of Health and Human Services or the Texas Department of Health and the Environment. You will not be penalized for the complaint
I acknowledge that I have offered a copy of the Financial Agreement, Notice of Privacy Practices and Treatment Consent. I have read them, been given the opportunity to ask questions, and my questions have been answered satisfactorily. I acknowledge that I am signing these forms through an electronic signature pad and that the electronic image will become the original document and that copies of this image may be used in place of the original.