Notice of Privacy Practices
JOINT NOTICE of PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH
INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
The University of Texas Health Science Center at Houston (“UTHealth”) and UT Physicians (“UTP”) are committed to protecting Health Information about you. We create a record of the services you receive at UTHealth for use in your care and treatment. Typically, this record contains your health history, symptoms, examination and test results, diagnoses, treatment, and a plan for your future course of treatment. UTP and UTHealth document your Health Information in records that will be maintained in a confidential manner, as required by law. UTHealth and UTP, their professional staff, employees, and volunteers and all of their affiliated entities follow the privacy practices described in this Notice. However, UTHealth and UTP must use and disclose your Health Information to the extent necessary to provide you with quality health care.
Who Will Follow This Notice? This Notice describes UTHealth’s and UTP’s privacy practices, as well as the privacy practices of: (a) all component departments, sections, schools and units of UTHealth; (b) all employees, staff and other UTHealth and UTP personnel; and (c) any resident, fellow, or student we train in dental, medical, nursing or allied health services. The entire workforce in these entities, sites and locations follow the terms of this Notice. In addition, these entities, sites and locations may share Health Information with each other to further the treatment, payment and health care operations activities described in this Notice.
Our Duties. We are required by law to:
- Make sure that Health Information that identifies you is kept private;
- Let you know promptly if a breach occurs that may have compromised the privacy or security of your information;
- Give you this Notice of our legal duties and privacy practices with respect to your Health Information; and
- Follow the terms of this Notice as long as it is in effect. If we revise this Notice, we will follow the terms of the revised Notice as long as the revised Notice is in effect.
What Are Treatment, Payment, and Health Care Operations?
Treatment includes sharing information among health care providers involved in your care. For example, your physician may share information about your condition with the pharmacist to discuss appropriate medications, or with radiologists or other consultants in order to make a diagnosis. UTHealth and UTP may use your Health Information as required by your insurer or managed care company to obtain payment for your treatment. We also may use and disclose your Health Information to improve the quality of care we render, e.g., for review and training purposes.
How Else Will UTHealth and UTP Use My Health Information?
Unless you ask for restrictions on a specific use or disclosure, your Health Information may be used the following purposes:
- To carry out health care treatment, payment, and operations functions through UTHealth and UTP business associates.
- To family members or close friends involved in your care or payment for your treatment and to disaster relief agencies if you are involved in a disaster relief effort.
- For appointment reminders and to inform you of treatment alternatives or other benefits and services related to your health.
- For fundraising activities by UTHealth, but the information used will be limited.
- As required by law.
- Help with public health activities and safety issues.
- For health oversight activities, e.g., audits, inspections, investigations, and licensure notices.
- During lawsuits and disputes.
- To assist coroners, medical examiners, and funeral directors.
- To facilitate organ and tissue donation, if you are an organ donor.
- For certain research projects.
- To prevent a serious threat to health or safety.
- To address workers’ compensation, law enforcement, and other government requests
- We will also afford special privacy protections for drug and alcohol information.
Your Authorization Is Required for Other Disclosures. Except as described above, we will not use or disclose your Health Information unless you authorize (permit) UTHealth or UTP in writing to disclose your Health Information. If you initially give permission, you may revoke that permission, which will be effective only after the date of your written revocation.
You Have Rights Regarding Your Health Information. You have the following rights regarding your Health Information, provided that you make a written request to invoke those rights on the form provided by UTHealth or UTP:
- Right to request restriction. You may request limitations on the use or disclosures of your Health Information we use or disclose for health care treatment, payment, or operations.
- Right to confidential communications. You may request that we communicate in a certain way or at a certain location, but you must specify how or where you wish to be contacted.
- Right to inspect and copy. You have the right to inspect and copy your Health Information.
- Right to request amendment. You may request an amendment or you may request to attach an additional statement to your records if you believe the Health Information we have about you in your record is incorrect or incomplete.
- Right to accounting of disclosures. You may request a list of the disclosures of your Health Information that have been made to persons or entities other than for health care treatment, payment or operations in the past six (6) years.
- Right to a copy of this Notice. You may request a paper copy of this Notice at any time. You may obtain an electronic copy of this Notice at our web site, http://www.uth.edu/index/privacy-practices.htm.
Requirements Regarding This Notice. UTHealth and UTP are required by law to provide this Notice to you. This Notice will bind us for as long as it is in effect. UTHealth may change this Notice and these changes will be effective for Health Information we have about you as well as any information we receive in the future. Each time you register at UTHealth or UTP for health care services, you may receive a copy of the Notice in effect at that time.
Complaints. If you believe your privacy rights have been violated, you may file a complaint with UTHealth, UTP or with the Secretary of the United States Department of Health and Human Services. You will not be penalized or suffer retaliation for making a complaint to UTHealth, UTP or the Department of Health and Human Services.
Contact: Please contact the Privacy Officer at 713-500-3391 if:
- you have a complaint;
- you have any questions about this Notice; or
- you wish instructions to obtain a form to exercise your individual rights.
FURTHER EXPLANATION OF USES AND DISCLOSURES OF HEALTH INFORMATION:
How We May Use And Disclose Health Information About You.
The following categories describe different ways that we use and disclose Health Information. For each category of uses or disclosures we will explain what we mean, and we may provide an example. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the bold-face print categories, below.
- For Treatment. We may use Health Information about you to provide you with medical or dental treatment or services. We may disclose Health Information about you to dentists, physicians, nurses, technicians, therapists, residents, students, or other personnel who are involved in your care. We may also disclose Health Information about you to people outside UTHealth or UTP who may be involved in your health care, such as physicians who will provide follow-up care. For example, your physician may share information about your condition with your pharmacist to discuss appropriate medications, or with radiologists or other consultants in order to make a diagnosis. A UTHealth or UTP clinician may, while referring you to another health care provider outside of UTHealth or UTP, disclose your Health Information to that provider.
- For Payment. We may use and disclose Health Information about you so that the treatment and services you receive at UTHealth and UTP may be billed to and payment may be collected from you, your insurance company, your managed care company, or a third party. We may also tell your health plan about a treatment you are going to receive in order to obtain prior approval.
- For Health Care Operations. We may use and disclose Health Information about you for UTHealth and UTP operations. These uses and disclosures are necessary to run UTHealth and UTP, to make sure that all of our patients receive quality care and for UTHealth education and other teaching programs. We may also disclose information to physicians, dentists, nurses, technicians, house-staff (including residents and fellows), dental, medical, or nursing students, and other personnel to conduct training programs. We may also combine Health Information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. Your Health Information may also be used or disclosed to comply with the law or regulations , patients’ claims, grievances or lawsuits, health care contracting, legal services, business planning and development, business management and administration, underwriting and other insurance activities and to operate UTHealth or UTP. We may also remove all information that identifies you from this set of Health Information so that others may use that information to perform research into health care and health care delivery without learning who specific patients are.
- To Business Associates for Treatment, Payment, and Health Care Operations. There are some services that we provide through contracts with business associates. We may disclose Health Information about you to one of our business associates in order to carry out treatment, payment, or health care operations. We require these business associates to protect your privacy in the same manner we do.
- Individuals Involved in Your Care or Payment for Your Care. To the extent allowed by law and how you direct us, we may release Health Information about you to a family member, other relative, or close personal friend who is involved in your health care if the Health Information released is directly relevant to such person’s involvement with your care. If permitted by law, we may also release information to someone who helps pay for your care. In addition, we may disclose Health Information about you to an entity assisting in a disaster relief effort so that your family can be notified about your location and general condition.
- Appointment Reminders. We may use Health Information in order to contact you as a reminder that you have an appointment at UTHealth or UTP.
- Health-Related Benefits and Services and Treatment
- Alternatives. We may use Health Information to tell you about health-related benefits and services that may be of interest to you. We may use Health Information in order to provide information to you about treatment options or alternatives that may be of interest to you.
- Fundraising Activities. We may use limited Health Information about you in order to contact you in an effort to raise money for UTHealth and its operations. The limited Health Information that would be used by UTHealth may include demographic information about you (e.g., your name, address, phone number), your doctor, your condition, and the dates you received treatment or services at UTHealth or UTP. Any request for donations you receive will include information about opting out of further fundraising communications, and we will comply with your request to opt out.
- As Required By Law. We will disclose Health Information about you when required to do so by federal, state, or local law.
- Public Health and Patient Safety Activities. We may disclose Health Information about you for public health purposes. These purposes generally include:
- Preventing or controlling disease (such as cancer or tuberculosis), injury, or disability;
- Reporting births and deaths;
- Reporting child abuse or neglect;
- Reporting reactions to medications or problems with certain products;
- Notifying people of recalls of certain products they may be using;
- Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
- Providing schools with immunization records, but after you agree we can give the records; and
- Notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
- Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law such as audits, investigations, inspections, and licensure. These activities are necessary for the state and federal government to monitor the health care system, government programs, and compliance with civil rights laws.
- Lawsuits and Disputes. We may disclose Health Information about you in response to a court or administrative order. If you are involved in a lawsuit, we may, as authorized by law, disclose Health Information about you in response to a subpoena, discovery request, or other lawful process.
- Law Enforcement. We may release Health Information if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons, or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person, but only if limited information is disclosed;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct we believe occurred on the premises of UTHealth or UTP; and
- In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.
- Coroners, Health Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner to identify a deceased person or to determine the cause of death. We may also release Health Information to funeral directors as necessary to carry out their duties.
- Organ and Tissue Donation. We may release Health Information to organizations involved in organ procurement or organ, eye, or tissue transplantation or if you are an organ donor to an organ donation bank to facilitate organ or tissue donation and transplantation.
- Research. UTHealth is a research institution. We may use and disclose Health Information for research purposes, subject to the confidentiality provisions of state and federal law. All research projects conducted by UTHealth are approved through a special review process to protect patient safety, welfare, and confidentiality. This special approval process requires an evaluation of the proposed research project and its use of Health Information. Before we use or disclose Health Information for research, the project generally will have been approved through this special approval process. However, this special approval process is not required when we allow Health Information about you to be reviewed by people who are preparing a research project and who work to review information about patients with specific health needs, so long as the Health Information does not leave our facilities.
- To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information about you when necessary to prevent a serious threat to your health and safety or to the health and safety of the public or another person. Any disclosure, however, would only be to someone who is able to help prevent the threat.
- Armed Forces and Foreign Military Personnel. We may release Health Information about you to the extent authorized by law, if you are or were a member of the Armed Forces. We may also release Health Information about foreign military personnel to the appropriate foreign military authority to the extent authorized by law.
- National Security and Intelligence Activities. We may release Health Information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities to the extent authorized by law.
- Protective Services for the President and Others. We may disclose Health Information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.
- Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information about you to a correctional institution or law enforcement official to the extent authorized or required by law.
- Workers’ Compensation. We may release Health Information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
- When Your Authorization Is Required. Other uses or disclosures of your Health Information for other purposes or activities, not listed above, will be made only with your written authorization (permission). We never share your information without an authorization for marketing purposes, to sell your information, and most sharing of psychotherapy notes. You may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose Health Information about you for the reasons covered by your written permission. We are unable, however, to retrieve any disclosures we have already made with your permission.
- Special Privacy Protections for Alcohol and Drug Abuse Information. Alcohol and drug abuse Health Information enjoys special privacy protections. UTHealth or UTP will not disclose any information identifying an individual as being a patient, or provide any Health Information, relating to a patient’s substance abuse treatment unless: (i) the patient consents in writing; (ii) a court order requires disclosure of the information; (iii) health personnel need the information to meet a health emergency; (iv) qualified personnel use the Health Information for the purpose of conducting scientific research, management audits, financial audits, or program evaluation; or (v) it is necessary to report a crime or a threat to commit a crime, or to report abuse or neglect as required by law.
FURTHER EXPLANATION OF YOUR RIGHTS:
Your Rights. You have the following rights regarding Health
Information we maintain about you:
- Right to Inspect and Copy. You have the right to inspect and copy Health Information that may be used to make decisions about your care. Usually, this includes health and billing records; but may not include psychotherapy notes. We may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain, very limited circumstances. If you are denied access to your Health Information, you may request that the denial to inspect and copy be reviewed. Another licensed health care professional chosen by UTHealth will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose about you to someone who is involved in your care, or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a particular surgery that you have had. In some cases, we will not be able to say “yes” to your request. However we will always agree if you pay for a service or health care item out-of-pocket in full and you ask us not to share that information for the purpose of payment or our operations with your health insurer. We will comply with your request unless the information is needed to provide you with emergency treatment, if we do agree.
- Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you by telephone at work or that we only contact you by mail at home. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- Right to Amend or Add an Addendum. If you feel that Health Information we have about you is incorrect or incomplete, you may ask us to amend or add to the Health Information. You have the right to request an amendment for as long as the information is kept by or for UTHealth or UTP. You must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (i) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (ii) is not part of the Health Information kept by or for UTHealth or UTP; (iii) is not part of the information which you would be permitted to inspect and copy; or (iv) is accurate and complete.
- Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures” to outside parties by UTHealth or UTP of your Health Information that occurred in the past six (6) years. This accounting is a list of the disclosures we made after April 14, 2003 of your Health Information for purposes other than treatment, payment, and health care operations, as those functions are described above. Your request must state a time period, which may not include dates before April 14, 2003. Your request should indicate in what form you want the list (e.g., on paper, electronically). The first list you request within a twelve (12) month period will be free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
- Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
- Access to Electronic Copy of This Notice. You may obtain an electronic copy of this Notice at our web site http://www.uth.tmc.edu/hipaa/documents.htm.
CHANGES TO THIS NOTICE. We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for Health Information we already have about you, as well as any Health Information we receive in the future. We will post a copy of the current Notice in all clinical areas. The Notice will contain on the second page, in the lower left-hand corner, the effective date. In addition, each time you register for treatment or health care services, we will offer you a copy of the current Notice in effect.
COMPLAINTS. If you would like a paper copy of this Notice, have questions about it, or believe its terms or any UTHealth or UTP privacy or confidentiality policy has been violated with respect to Health Information about you, please contact us immediately at The University of Texas Health Science Center at Houston Privacy Office, 7000 Fannin Suite 1470, Houston, Texas 77030 or by phone 713-500-3391. Please include your name, address, and a telephone number where we can contact you, and a brief description of the complaint. If you prefer, you may lodge an anonymous complaint. You may also contact the Secretary of the Department of Health and Human Services at: Region VI, Office for Civil Rights, U.S. Department of Health and Human Services, 1301 Young Street, Suite 1169, Dallas, TX 75202. Phone (214) 767-4056. FAX (214) 767-0432. TDD (214) 767-8940. You will not be penalized or suffer retaliation in any way for making a complaint to UTHealth, UTP or the Department of Health and Human Services. Please provide as much information possible so that the complaint can be properly investigated. Neither UTHealth, UTP nor any of its affiliates will retaliate against a person who files a complaint with us or with Secretary of Department of Health and Human Services.
PRIVACY OFFICER. If you have any questions about this Notice, please contact the Privacy Office at 713-500-3391.
Effective Date: September 19, 2013
Reviewed on 4/30/2018