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OUR
LEGAL DUTY
We are required by applicable federal and
state law to maintain the privacy of your
health information. We are also required to
give you this Notice about our privacy practices,
our legal duties, and your rights concerning
your health information. We must follow the
privacy practices that are described in this
Notice while it is in effect. This notice
takes effect August 1, 2006, and will remain
in effect until we replace it.
We
reserve the right to change our privacy practices
and the terms of this Notice at anytime, provided
such changes are permitted by applicable law.
We reserve the right to make the changes in
our privacy practices and the new terms of
our Notice effective for all health information
that we maintain, including health information
we created or received before we made the
changes. Before we make a significant change
in our privacy practices, we will change this
Notice and make the new Notice available upon
request.
You
may request a copy of our Notice at any time.
For information about our privacy practices,
or for additional copies of this Notice, please
contact us using the information listed at
the end of this Notice.
USES
AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about
you for treatment, payment, and healthcare
operations. For example:
· Treatment:
We may use or disclose your health information
to a physician or other healthcare provider
providing treatment to you.
· Payment:
We may use and disclose your health information
to obtain payment for services we provide
to you.
· Healthcare Operations:
We may use and disclose your health information
in connection with our healthcare operations.
Healthcare operations include quality assessment
and improvement activities, reviewing the
competence or qualifications of healthcare
professionals, evaluating practitioner and
provider performance, conducting training
programs, accreditation, certification, licensing
or credentialing activities.
·
Your Authorization:
In addition to our use of your health
information for treatment, payment or
healthcare operations, you may give us
written authorization to use your health
information or to disclose it to anyone
for any purpose. If you give us an authorization,
you may revoke it in writing at anytime.
Your revocation will not affect any use
or disclosures permitted by your authorization
while it was in effect. Unless you give
us a written authorization, we cannot
use or disclose your health information
for any reason except those described
in this Notice.
· To Your Family and Friends:
We must disclose your health information
to you, as described in the Patients Rights
section of this Notice. We may disclose
your health information to a family member,
friend, or other person to the extent
necessary to help with your healthcare
or with payment for your healthcare, but
only if you agree that we may do so.
· Persons Involved In Care:
We may use or disclose health information
to notify, or assist in the notification
of (including identifying or locating)
a family member, your personal representative,
or another person responsible for your
care, of your location, your general condition,
or death. If you are present, then prior
to use or disclosure of your health information,
we will provide you with an opportunity
to object to such uses or disclosures.
In the event of your incapacity or emergency
circumstances, we will disclose health
information that is directly relevant
to the person's involvement in your healthcare.
· Marketing Health-Related Services:
We will not use your health information
for marketing communications without your
written authorization.
· Required by Law:
We may use or disclose your health information
when we are required to do so by law.
· Abuse or Neglect:
We may disclose your health information
to appropriate authorities if we reasonably
believe that you are a possible victim
of abuse, neglect, or domestic violence
or the possible victim or other crimes.
We may disclose your health information
to the extent necessary to avert a serious
threat to your health or safety or the
health or safety of others.
· National Security:
We may disclose to military authorities
the health information of Armed Forces
personnel under certain circumstances.
We may disclose to authorized federal
officials health information required
for lawful intelligence, counterintelligence,
and other national security activities.
We may disclose to correctional institutions
or law enforcement officials having lawful
custody, the protected health information
of an inmate-patient under certain circumstances.
CLIENT RIGHTS
· Access:
You have the right to look at or get copies
of your health information, with limited
exceptions. You may request that we provide
copies in a format other than photocopies.
We will use the format you request unless
we cannot practicably do so. (You must
make a request in writing to obtain access
to your health information. You may obtain
a form to request access by using the
contact information listed at the end
of this Notice. We will charge you a reasonable
cost-based fee for expenses such as copies
and staff time. You may also request access
by sending us a letter to the address
at the end of this Notice. If you request
copies, we will charge you $10.00 plus
$ .25 for each page copied. Also a $10.00
handling fee for processing the request
and postage will be added if you request
that the documents to be mailed. If you
request an alternative format, we will
charge a cost-based fee for providing
your health information in that format.
If you prefer, we will prepare a summary
or an explanation of your health information
for a fee. Contact us using the information
listed at the end of this Notice for a
full explanation of our fee structure.)
· Disclosure Accounting:
You have the right to receive a list of
instances in which we or our business
associates disclosed your health information
for purposes, other than treatment, payment,
healthcare operations and certain other
activities, for the last 6 years, but
not before June 1, 2006. If you request
this accounting more than once in a 12-month
period, we may charge you a reasonable,
cost-based fee for responding to these
additional requests.
· Restrictions:
You have the right to request that we
place additional restrictions on our use
or disclosure of your health information.
We are not required to agree to these
additional restrictions, but if we do,
we will abide by our agreement (except
in an emergency).
· Alternative Communication:
You have the right to request that we
communicate with you about your health
information be alternative means or to
alternative locations. (You must make
your request in writing.) Your request
must specify the alternative means or
location, and provide satisfactory explanation
how payments will be handled under the
alternative means or location you request.
· Amendment:
You have the right to request that we
amend your health information. (Your request
must be in writing, and it must explain
why the information should be amended.)
We may deny your request under certain
circumstances.
· Electronic Notice:
If you receive this Notice on our Web
site or by electronic mail (e-mail), you
are entitled to receive this Notice in
written form.
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QUESTIONS
AND COMPLAINTS
If you want more information about our privacy
practices or have questions or concerns, please
contact us.If
you are concerned that we may have violated
your privacy rights, or you disagree with
a decision we made about access to your health
information or in response to a request you
made to amend or restrict the use or disclosure
of your health information or to have us communicate
with you be alternative means or at alternative
locations, you may complain to the U.S. Department
of Health and Human Services. We will provide
you with the address to file your complaint
with the U.S. Department of Health and Human
Services upon request. We support your rights
to the privacy of your health information.
We will not retaliate in any way if you choose
to file a complaint with us or with the U.S.
Department of Health and Human Services.
Contact
Privacy Officer:
Deedee Gregoire, LCSW, Clinical Director
Phone: (409) 762-8636
Fax: (409) 762-4185
E-mail: dgregoire@ev1.net
Address:
2200 Market Street, Suite 600
Galveston, Texas 77550
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