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 notice takes effect on May 10, 2004 and remains in effect until we replace it.
1. OUR PLEDGE REGARDING MEDICAL INFORMATION
The privacy of your medical information is important to us. We understand that your medical information is
personal and we are committed to protecting it. We create a record of the care and services you receive at our
organization. We need this record to provide you with quality care and to comply with certain legal
requirements. This notice will tell you about the ways we may use
and share medical information about you. We also describe your rights and certain duties we have regarding the
use and disclosure of medical information.
2. OUR LEGAL DUTY
Law Requires Us to:
1. Keep your medical information private.
2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical
information.
3. Follow the terms of the current notice.
We Have the Right to:
1. Change our privacy practices and the terms of this notice at any time, provides that the changes are permitted
by law.
2. Make the changes in our privacy practices and the new terms of our notice effective for all medical
information that we keep,
including information previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before we make an important change in our privacy practices, we will change this notice and make the new
notice available
upon request.
3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways that we use and disclose medical information. Not every use or
disclosure will be
listed. However, we have listed all of the different ways we are permitted to use and disclose medical
information. We will not use or disclose your medical information for any purpose not listed below, without
your specific written authorization. Any specific written authorization your provide may be revoked at any time
by writing to us at the address provided at the end of this notice.
FOR TREATMENT: We may use medical information about you to provide your with medical treatment or
services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or
other people who are taking care of you. We may also share medical information about you to your other health
care providers to assist them in treating you.
FOR PAYMENT: We may use and disclose your medical information for payment purposes. A bill may be sent
to you or a third-party payer. The information on or accompanying the bill may include your medical
information.
FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care
operations. This might include measuring and improving quality, evaluating the performance of employees,
conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to
serve you.
ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information s for
treatment, payment, and health care operations, we may use and disclose medical information for the following
purposes.
Facility Directory: Unless you notify us that you object, the following medical information about your will be
place in our facility directories: your name; your location in our facility; your condition described in general
terms; your religious affiliation, if any. We may disclose this information to member of the clergy or, except for
your religious affiliation, to other who contact us and ask for
information about your by name.
Notification: We may use and disclose medical information to notify or help notify: a family member, your
personal
representative or another person responsible for your care. We will share information about your location,
general condition, or death. If you are present, we will get your permission if possible before we share, or give
your the opportunity to refuse permission, In care of emergency, and if you are not able to give or refuse
permission, we will share only the health information that is directly necessary for your health care, according to
our judgment. We will also use our professional judgment to make
decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-rays or medical
information for you.
Disaster Relief: We may share medical information with a public or private organization or person who can
legally assist in disaster relief efforts.
Fund Raising: We may provide medical information to one of out affiliated fund raising foundations to contact
your for fund raising purposes. We will limit our use and sharing to information that describes you in general,
not personal, terms and the dated of your health care. In any fund raising materials, we will provide you a
description of how your may choose not to receive future fund raising communications.
Research in Limited Circumstances: We may use medical information for research purposes in limited
circumstances where the research has been approved by a review board that has reviewed the research proposal
and established protocols to ensure the privacy of medical information.
Funeral Director, Coroner, and Medical Examiner: To help them carry out their duties, we may share the
medical information of a person who has died with a coroner, medical examiner, funeral director, or an organ
procurement organization.
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information
for military personnel and veterans, for national security and intelligence activities, for protective services for the
President and others, for medical suitability determinations for the Department of State, for correctional
institutions and others, for correctional institutions and other law enforcement custodial situations and for
government programs providing public benefits.
Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to
a court or administrative order, subpoena, discovery request, or other lawful process, under certain
circumstances. Under limited circumstances, such as court order, warrant, or grand jury subpoena, we may
share your medical information with law enforcement officials. We may share limited information s with a law
enforcement official concerning the medical information of an
inmate or other person in lawful custody with a law enforcement official or correctional institution under certain
circumstances.
Public Health Activities: As required by law, we may disclose your medical information to public health or legal
authorities charged with preventing or controlling disease, injury or disability, including child abuse of neglect.
We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug
Administration for purposes of reporting adverse events associated with product defects or problems, to enable
product recalls, repairs or replacements, to track products, or to conduct activities require by the Food and Drug
Administration. We may also, when we are authorized by law to do so, notify a person who may have been
exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.
Victims of Abuse, Neglect, or Domestic Violence: We may use and disclose medical information to appropriate
authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence of the
possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious
threat to your health or safety or the health or safety of others. We may share medical information when
necessary to help law enforcement officials capture a person who has admitted to being a part of a crime or has
escaped from legal custody.
Workers Compensation: We may disclose health information when authorized or necessary to comply with laws
relating to workers compensation or other similar programs.
Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement
officials. These circumstances include reporting required by certain laws (such as the reporting of certain types
of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning
identification and location at the request of a law enforcement official, reports regarding suspected victims of
crimes at the request of a law enforcement official, reporting death,
crimes on our premises, and crimes in emergencies.
Appointment Reminders: We may use and disclose medical information for purposes of sending your
appointment postcards or otherwise reminding you of your next appointments.
Alternative and Additional Medical Services: We may use and disclose medical information to furnish you with
information about health-related benefits and services that may be of interest to you and to describe or
recommend treatment alternatives.
4. YOUR INDIVIDUAL RIGHTS
You Have a Right to:
1. Look at or get copies of certain parts of our medical information. Yo may request that we provide copies in a
format other that photocopies. We will use the format you request unless it is not practical for us to do so. You
must make your request in writing. You may get the form to request access by using the contact information
listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the
end of this notice. If you request copies, we will charge you $1.00 for each page, and postage if you want the
copies mailed to you. Contact us using the information listed at the end of this notice for a full explanation of
our fee structure.
2. Receive a list of all the times we or out business associated shared your medical information for purposes
other than treatment, payment, and health care operations and other specified exceptions.
3. Request that we place additional restrictions on our use or disclosure of your medical information. We are not
required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the
case of an emergency)
4. Request that we communicate with you about your medical information by different means or to different
locations. Your request that we communicate your medical information to you by different means or at different
location must be made in writing to the contact person listed at the end of this notice.
5. Request that we change certain parts of your medical information. We may deny your request if we did not
create the information you want changed or for certain other reasons. If we deny your request, we will provide
you a written explanation. You may respond with statement of disagreement that will be added to the
information you wanted changed. If we accept your request to change the information, we will make reasonable
efforts to tell others, including people you name, of the change and
to include the changed in any future sharing of that information.
6. If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain
a paper copy by making a request in writing to the contact person listed at the end of this notice.
QUESTIONS AND COMPLAINTS
If you have any questions about this notice or if you think that we may have violated your privacy rights, please
contact us. You may also submit a written complaint to the U.S. Department of Health and Human Services.
You may contact us to submit a complaint or submit requests involving any of your rights in Section 4 of this
notice by writing to the following address:
CRAWFORD WELLNESS CENTER
5218 CEDAR ST. STE. A
BELLAIRE, TX 77401
TELEPHONE: (713) 503-9687
FAX: (713) 668-8039
We will provide you with the address to file your complaint with the U.S. Department of Health and Human
Services. We will not retaliate in any way if you choose to file a complaint.
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| NOTICE OF PRIVACY PRACTICES CRAWFORD WELLNESS CENTER, INC. 5218 Cedar St., Ste. A Bellaire, TX 77401 Telephone: (713) 503-9687 |