Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed, and how you can gain access to your individually identifiable health information.

PLEASE REVIEW THIS NOTICE CAREFULLY

A. OUR COMMITMENT TO YOUR PRIVACY:

Caritas Pediatrics and Wellness, PLLC (the Practice or We), is dedicated to maintaining the privacy of your personally identifiable, protected health Information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We strive to maintain the confidentiality of health information that identifies you. This notice explains the privacy practices that we maintain concerning your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by the Practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will affect all of your records that our Practice has created or maintained in the past and any records of yours that we may create or maintain in the future. You may request a copy of our most current notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: 

Caritas Pediatrics and Wellness, PLLC

300 Beardsley Lane, Bldg E, Suite 101

Austin, Texas 78746

C. WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS:

The following categories describe the different ways in which we may use and disclose your PHI, unless you object:

1. Treatment. Our Practice may use your PHI in the course of your treatment.  For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Our staff may use or disclose your PHI to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as other healthcare providers, your spouse, your children, or your parents.
2. Payment. Our Practice may use and disclose your PHI to bill and collect payment for the services and products you may receive from us. We do not participate or bill insurance, so we do not disclose your information for the purpose of being reimbursed by insurance. However, we may use and disclose your PHI to obtain payment from those who may be responsible for such costs, such as family members.
3. Health Care Operations. The Practice may use and disclose your PHI to operate our business. For example, we may use and disclose your information for our operations, our Practice may use your PHI to evaluate the quality of care you received from us, to develop protocols and clinical guidelines, to develop training programs, or to aid in credentialing and medical review. 
4. Appointment Reminders. The Practice may use and disclose your PHI to contact you and remind you of an appointment.
5. Release of Information to Family/Friends. The Practice may release your PHI when necessary, to a friend or family member involved in your care. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.
6. Disclosures Required by Law. The Practice will use and disclose your PHI when we are required to do so by federal, state, or local law or regulation.

D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL

CIRCUMSTANCES:

The following categories describe unique scenarios in which we may use or disclose your PHI:

When required by law to collect information for the purpose of:

1. Health Oversight Activities. The Practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions and other activities necessary for the government to monitor its programs, compliance with civil rights laws, and the health care system in general.
2. Lawsuits and Similar Proceedings. The Practice may use and disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process, by another party involved in the dispute. But we shall only disclose PHI after we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
3. Law Enforcement. We may release PHI if required to do so by a law enforcement official:

• regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement; 
• concerning a death we believe has resulted from criminal conduct;
• regarding criminal conduct at our offices;
• in response to a warrant, summons, court order, subpoena, or similar legal process;
• to identify or locate a suspect, material witness, fugitive or missing person;
• in an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity, or location of the perpetrator).

1. Deceased Patients. The Practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information to funeral directors as necessary to perform their jobs.
2. Organ and Tissue Donation. If you are an organ donor, the Practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation.
3. Serious Threats to Health or Safety. The Practice may use and disclose your PHI when necessary, to reduce or prevent a serious threat to your health and safety or that of another individual or the public. But we will only make such disclosures to a person or organization able to help prevent the threat.
4. Military. The Practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
5. Public Health Risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of: 

• maintaining vital records, such as births and deaths 
• reporting child abuse or neglect 
• preventing or controlling disease, injury, or disability 
• notifying a person regarding potential exposure to a communicable disease 
• notifying a person regarding a potential risk for spreading or contracting a disease or condition 
• reporting reactions to drugs or problems with products or devices 
• notifying individuals if a product or device they may be using has been recalled 
• notifying appropriate government agency (ies) and authority (ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees, or we are required or authorized by law to disclose this information 
• notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

E. YOUR RIGHTS REGARDING YOUR PHI:

The health and billing records we maintain are the physical property of Practice. The information in it, however, belongs to you. You have a right to:

1. Confidential Communications. You have the right to request that our Practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. To request a specific type of confidential communication, you must make a written request to the Privacy Officer, identifying the requested method of contact, or location where you wish to be contacted. Our Practice will accommodate reasonable requests. You do not need to give a reason for your request.
2. Request Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. To request a restriction on our use or disclosure of your PHI, you must make your request in writing to the Privacy Officer. Your request must describe in a clear and concise fashion:
   a. the information you wish restricted;
   b. whether you are requesting to limit our Practice’s use, disclosure, or both; and
   c. to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you and your care, including your billing and medical records, but not your psychotherapy notes. In order to inspect and/or obtain a copy of your PHI, you must submit your request in writing to the Privacy Officer. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. The review shall be conducted by a different licensed health care professional of our choosing. 
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our Practice. To request an amendment, your request must be made in writing and submitted to the Privacy Officer. You must provide us with a reason that supports your request for amendment. Our Practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion:
   a. accurate and complete;
   b. not part of the PHI kept by or for the Practice;
   c. not part of the PHI which you would be permitted to inspect and copy; or
   d. not created by our Practice, unless the individual or entity that created it is not available to amend the information.
5. Paper Copy of this Notice. You may receive a paper copy of our notice of privacy practices anytime, upon request by contacting the Privacy Officer.
6. Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our Practice. To file a complaint, contact our privacy officer at the address provided above.  Caritas Pediatrics and Wellness, PLLC
   Attn: Privacy Officer
   All complaints should be submitted in writing, and you will not be penalized for filing a complaint. You will not be penalized for filing a complaint.
7. Right to Provide an Authorization for Other Uses and Disclosures. Our Practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. You have the right, at any time, to revoke your authorization to disclose your PHI. Simply send a written notice of revocation to the Privacy Officer at the address provided above. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

Again, if you have questions regarding this notice or our health information privacy policies, please contact the Privacy Officer listed above.

ACKNOWLEDGEMENT

I hereby acknowledge that I have received and read Caritas Pediatrics and Wellness, PLLC’s HIPAA Privacy Policy Notice. I understand that I may request additional copies of this notice at any time.

Patient’s full name: ___________________

Patient’s Date of Birth:_________________

Signature: _________________________

Date: ____________________________

Printed Name: ______________________

Relationship to Patient: ________________

HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office. 

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov 

We have adopted the following policies: 

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. 
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. 
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the practice.
6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services. 
7. We agree to provide patients with access to their records in accordance with state and federal laws. 
8. We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient. 
9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request. 

I,___________________________ date ____________do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.