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Randy A. Birken, M.D., P.A.
NOTICE OF PRIVACY PRACTICES
EFFECTIVE DATE OF NOTICE: April 14, 2003
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.
If you have any questions about this Notice, please
contact Freida Barlow-Hernandez, our Office Manager at
(281) 893-1246.
OUR COMMITMENT TO YOUR PRIVACY
The federal Health Insurance Portability and
Accountability Act (HIPAA) of 1996 contains provisions
that give you greater access to your health
information – your medical record, your billing and
insurance records, and any other information our
practice might collect from you to provide healthcare
services to you or to receive payment for the
healthcare services rendered. In essence, HIPAA
provides you with greater control over how your health
information is used and disclosed.
HIPAA also outlines the responsibilities that
healthcare providers and insurance plans have to keep
your health information confidential. For example,
HIPAA requires we provide you with this Notice and
that we follow its terms and the commitments we make
in it.
Randy A. Birken, M.D., P.A. is dedicated to
maintaining the privacy of your health information.
In conducting our business, we will create records
regarding you and the treatment and services we
provide to you.
These records are our property. However, as required
by law, we will:
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Maintain the confidentiality of your
health information.
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Provide you with this Notice of our
legal duties and privacy practices concerning your
health information.
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Follow the terms of our Notice of
Privacy Practices in effect at the time.
In
addition, unless it is specifically provided for by
state or federal law, we may not use or disclose your
health information without your written
authorization. You may revoke your authorization at
any time.
CHANGES TO THIS
NOTICE
The terms of this Notice apply to all records
containing your health information that are created or
retained by us. We reserve the right to revise,
change, or amend our Notice of Privacy Practices. Any
revision or amendment to this Notice will be effective
for all of the information that we already have about
you, as well as any of your health information that we
may receive, create, or maintain in the future. Our
practice
will post a copy of our current Notice in our offices
in a prominent location, and you may request a copy of
our most current Notice during any visit to our
practice.
HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
The following categories describe the different ways
in which HIPAA allows Randy A. Birken, M.D., P.A. to
use and disclose your health information without
your authorization. We have not provided an
exhaustive list of every type of use or disclosure we
are permitted to make. The different ways we are
permitted to use and disclose your health information
do fall within one of the following categories.
Treatment
Our practice will use and disclose your health
information as necessary for you to receive
treatment. For example, we may order some laboratory
tests (such as blood and urinalysis) and use the
results to help us reach a diagnosis, to provide
further treatment to you, or to assist others in your
treatment. Additionally, we may disclose your health
information to others outside our practice that may
assist in your care, such as other healthcare
providers, caregivers, or members of your family.
Payment
Our organization will use and disclose your health
information in order to bill and collect payment for
the services and items you receive from us. For
example, we may contact your health insurer to confirm
you are eligible for benefits and for what range of
benefits. We may be asked by your insurer to provide
specific details about the treatment you received so
your insurer can determine whether the costs of your
treatment are reimbursable. We also may use and
disclose your health information to obtain payment
from third parties that may be responsible for such
costs, such as members of your family. Also, we may
use your information to bill you directly for the
services we provide during your treatment.
Health Care
Operations
Randy A. Birken, M.D., P.A. will use and disclose your
health information internally to help ensure that you
receive quality care and that we run efficiently and
in compliance with state and federal laws. We may
disclose your information to state surveyors to help
us evaluate the quality of care we provide. Similarly,
we may use your health information to conduct
cost-management and planning activities to identify
new services needed for our patients. Whenever we use
or disclose your health information for these
purposes, we will, to the extent possible, delete any
information that could be used to identify you such as
your name, your address and telephone number, your
Social Security Number, etc.
Appointment Reminders
Our practice will use and disclose your health
information to remind you that you have an
appointment.
Alternative Treatments/Health-Related Benefits and
Services
Our practice will use and disclose your health
information to inform you of treatment alternatives
and/or health-related benefits and services that may
be of interest to you.
Disclosures to Those Involved in Your Healthcare
Unless you object, we may disclose your health
information to a family member, relative, close
friend, or any other person that you identify who has
involvement in your care or with payment related to
your care. We will, however, disclose only that
health information that is directly related to the
person’s involvement. If you are unable to agree or
object to a disclosure, we will use our professional
judgment to determine whether the health information
should be disclosed to these individuals.
OTHER PERMITTED USES AND DISCLOSURES
As
Required by Law
Randy A. Birken, M.D., P.A. will use or disclose
health information about you when required to do so by
applicable state or federal law. For example, a
physician is required to report individuals who
receive treatment for gunshot wounds to the state. If
you receive treatment for a gunshot wound, we will
provide your health information to the appropriate
state agency.
For Public Health Activities
Our organization may disclose your health information
for various public health activities. For example, we
will disclose your health information to notify a
person about potential exposure to a communicable
disease or a potential risk for spreading or
contracting a disease or condition. Similarly, we
will disclose your health information to report
reactions to drugs, problems with products or devices,
or to notify you if a device you have has been
recalled. In addition, we may, in certain limited
situations, disclose your health information to your
employer if it relates to workplace injury or illness
or medical surveillance.
Victims of Abuse, Neglect, or Domestic Violence
We
will disclose your health information to the
appropriate government authority if we believe you are
a victim of abuse, neglect, or domestic violence. If
such a disclosure is made, you will be informed your
physician thinks informing you places you at risk of
serious harm or is otherwise not in your best
interest. For example, Randy A. Birken, M.D., P.A.
must notify Adult Protective Services if an elderly
person appears to have been a victim of neglect.
For Health Oversight Activities
Our practice may disclose your health information to a
health oversight agency for activities authorized by
law. Oversight activities can include, for
example, investigations, inspections, audits, surveys,
or licensure and disciplinary actions, and may be
conducted by either governmental or public agencies
and authorities.
For Lawsuits and Similar Proceedings
Our practice will use and disclose your health
information in response to a court or administrative
order if you are involved in a lawsuit or similar
proceeding. We also may disclose your health
information in response to a subpoena or other lawful
process by another party involved in the dispute, but
only if (1) we know the other party has informed you
of its request and you have not objected to them
receiving the information, (2) you have authorized use
to release the information, or (3) we have made an
effort to inform you of the request or to obtain an
order protecting the information the party has
requested.
To
Law Enforcement
We
will release your health information to law
enforcement officials if they ask for it, but only if
(1) the information sought is relevant and material to
a legitimate law enforcement inquiry, (2) the request
for your information is specific and limited in scope,
and 3) the request comes in the form of a warrant,
subpoena, or summons issued by a court. Most
importantly, the information we release to law
enforcement officials is limited to your contact
information. For example, we might provide the law
enforcement officer with your current address if you
were a victim of a crime and the law enforcement
officer needed the information to fill in his/her
report of that crime.
To
Coroners, Medical Examiners, and Funeral Directors
Our practice may release health information to a
coroner or medical examiner. This may be necessary,
for example, to identify a deceased person or to
determine the cause of death. We may also release
health information about patients of a hospital to
funeral directors as necessary to carry out their
duties.
For Organ and Tissue Donation Purposes
We
may disclose your health information to organizations
that handle organ and tissue procurement, banking, or
transplantation. For example, we might provide your
health information to an organ donation center if the
information were needed to include you on a list of
individuals awaiting an organ for transplant, or if
you are listed as an organ donor.
Research
Under certain circumstances, we may use and disclose
your health information for research purposes.
However, we will only disclose information that can be
used to identify you when the research that is being
conducted could not be conducted without this
identifying information.
Please be assured that all research projects are
subject to a special approval process that balances
the research needs with patients’ need for health
information privacy. Before we use or disclose your
health information for a research project, the project
will have been approved through this special approval
process. In very limited circumstances, we may allow
other healthcare professionals to review your health
information, but they must do so on our premises, and
will be allowed access to your health information only
in preparation for conducting a research project.
To
Avert a Serious Threat to Health or Safety
Our practice may use and disclose your health
information when necessary to reduce or prevent a
serious threat to your health and safety or the health
and safety of another individual or the public. Under
these circumstances, we will only make disclosures to
a person or organization able to help prevent the
threat.
For Specialized Government Functions
Our practice may disclose your health information if
you are a member of U.S. or foreign military forces
(including veterans) and if required to do so by the
appropriate military command authorities. In
addition, our practice may disclose your health
information to federal officials for intelligence and
national security activities authorized by law, such
as for protecting the President, other officials, or
foreign heads of state, or to conduct intelligence
operations or investigations.
Workers’ Compensation
Our practice will release your health information to
comply with laws relating to workers’ compensation and
similar programs.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
Under HIPAA, you have several specific rights
regarding the health information we maintain about
you. Some of these rights require you to contact
Randy A. Birken, M.D., P.A. in writing in order to
exercise them.
If you are required to contact Randy A. Birken, M.D.,
P.A. in writing, please submit your written request
to:
Freida Barlow-Hernandez, Office Manager
Randy A. Birken, M.D., P.A.
17070 Red Oak Dr., Suite 201A
Houston, TX 77090
Right to Request Restrictions
You have the right to ask that we limit how we use and
disclose your health information. Additionally, you
have the right to request that we limit any
disclosures we make of your health information to only
those individuals who are involved in your care or for
payment for your care.
We
are not
required to agree to your request; although we will
accommodate reasonable requests. Further, if we do
agree to your request, we are bound by our agreement
with you except when otherwise required by law, in
case of an emergency, or when the information we need
to use or disclose is necessary to treat you.
Requests for restrictions must be submitted in writing
to the above:
Your request must describe in a clear and concise
fashion: (1) the information you wish restricted; (2)
whether you are requesting to limit our practice’s
use, disclosure or both; and (3) to whom or how you
want the limits to apply.
Right to Receive Confidential Communications
You have the right to request the manner in which, and
where we should communicate with you regarding your
health information. For instance, you may direct us
to contact you by mail rather than by telephone, or at
work rather than at your home. You also have the
right to ask us to send your health information to you
at a location other than the one we have on file for
you. For example, you might want us to send your
health information to a post office box instead of
your home address.
In
order to receive a confidential communication or to
have communications sent to a different location, you
must submit your request in writing to the above:
Your request must specify the requested method of
contact and/or the location, as appropriate. You
are not required to give a reason for your request.
Randy A. Birken, M.D., P.A. will accommodate all
reasonable requests.
Right to Inspect and Copy
You have the right to inspect and obtain a copy of the
health information about you that we use and/or store,
including your medical records and insurance and
billing records.
If
you want to inspect or obtain a copy of your health
information, you must submit your request in writing
to the above:
Randy A. Birken, M.D., P.A. charges a fee that covers
the costs we incur to make the copies, send or mail
the health information to you, and any labor and
supplies required. We will inform you of the
estimated cost associated with your request before we
make copies for you in case you want to withdraw or
limit your request.
In
only a few, limited circumstances, Randy A. Birken,
M.D., P.A. will deny a patient’s request. If we deny
you access to your health information or a copy of
your health information, you may request a review of
the denial, which will be performed by a healthcare
provider chosen by us who was not involved in the
initial decision.
Right to Request Amendments
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 Randy A. Birken, M.D., P.A.. Your
request for amendment(s) must be made in writing and
submitted to the above:
In
your request, you must specify the reason(s) you
believe your information is incorrect or incomplete.
Failure to submit your request in writing and/or
failing to include the proper documentation will
result in a denial. In addition, your request will be
denied if you ask us to amend information that is:
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accurate and complete;
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not part of the health information kept
by or for Randy A. Birken, M.D., P.A.;
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not part of the health information which
you would be permitted to inspect and copy; or
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not created by Randy A. Birken, M.D.,
P.A., unless the individual or entity that created the
information is not available to amend the information
and Randy A. Birken, M.D., P.A. has all the
information required to evaluate and respond to your
request.
Right to Receive an Accounting of Disclosures
You have the right to request an accounting of
disclosures of your health information that have been
made by Randy A. Birken, M.D., P.A.. The accounting
of disclosures will not include: (1)
disclosures that are made in the course of providing
treatment to you; (2) disclosures that are made for
purposes of obtaining payment for the services
rendered to you; (3) disclosures that are made for
purposes of operating our practice; and (4) any
disclosures you previously authorized Randy A. Birken,
M.D., P.A. to make.
In
order to obtain an accounting of disclosures, you must
submit your request in writing to the above:
Your request must include a specific period of time
that may not be longer than six (6) years prior to the
date of the request, and the specific period of time
may not include dates prior to April 14, 2003.
The first accounting of disclosures you request in a
twelve (12) month period will be provided free of
charge. There will be a charge for any additional
accountings of disclosures requested within the same
(12) month period. Randy A. Birken, M.D., P.A. will
notify you of the costs associated with any additional
requests made by you. That way, you may withdraw or
limit your request prior to incurring any costs.
Right to a Paper Copy of This Notice
You are entitled to receive a paper copy of this
Notice of Privacy Practices the first time you come to
Randy A. Birken, M.D., P.A. for treatment. However,
you may ask for and we will provide you with a copy of
this Notice at any time. Please direct you request
for a copy of this Notice to Freida Barlow-Hernandez,
Office Manager at (281) 893-1246.
Right to File a Complaint
If
you believe Randy A. Birken, M.D., P.A. has misused or
improperly disclosed your health information, you may
file a complaint with our practice by contacting
Freida Barlow-Hernandez, our Office Manager at (281)
893-1246. Alternatively, you may file a complaint
with the Secretary of the Department of Health and
Human Services.
All complaints must be submitted in writing, either to
Randy A. Birken, M.D., P.A. or to the Department of
Health and Human Services. Complaints to Randy A.
Birken, M.D., P.A. should be sent to:
Randy A. Birken, M.D., P.A.
17070 Red Oak Dr.
Suite 201A
Houston, TX 77090
You will not be penalized for filing a complaint.
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 are not permitted by law. Any
authorization you provide to us regarding the use and
disclosure of your health information may be revoked
at any time, by you, in writing. After you
revoke your authorization, we will no longer use or
disclose your health information for the reasons
described in the authorization. Of course, we
are unable to take back any disclosures that we have
already made with your permission.
CONTACT
If
you have any questions about how Randy A. Birken,
M.D., P.A. will use or disclose your health
information, or if you require further information
about this Notice of Privacy Practices, please
contact:
Freida Barlow-Hernandez, Office Manager
Randy A. Birken, M.D., P.A.
17070 Red Oak Dr.
Suite 201A
Houston, TX 77090
(281) 893-1246
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