2023 OFFICE UPDATES
CHECK-IN BY PHONE. REMAIN IN CAR FOR INSTRUCTIONS. FACE COVERINGS ARE ENCOURAGED.
(Intersection of FM 1960 RD W. & Champions Forest)
5627 FM 1960 Road W. Suite 100
Houston, Texas 77069-4200
832-688-8946 | 281-894-3100
HIPAA NOTICE OF PRIVACY PRACTICES
LAST UPDATED ON May 1st, 2020
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.
The privacy of your medical information is very important to us, and we are committed to protecting your personal information. This notice describes how your medical records and information may be used and disclosed by Cy Fair Pediatrics to carry out treatment, payment, health care operations, or for other purposes that are permitted or required by law.
I. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
Your medical information consists of all records related to your health that are either created by our practice, or received by us from another healthcare provider.
Treatment – We may use and disclose your medical information to provide you with treatment or treatment-related services. Additionally, we may also disclose information about you with other providers or personnel who are involved in your care.
Payment - We may use and disclose your medical information for payment of treatment and services provided by our practice, which may be billed and collected from you, an insurance company, or a third party. In certain situations, disclosing your information is necessary to obtain prior approval or determine your eligibility and benefits from your insurance company.
Health Care Operations – We may use and disclose your medical information for business operations in order to continually improve the quality and effectiveness of our healthcare services.
Communication – We may use and disclose your medical information to remind you of an upcoming appointment or to relay a message to you regarding your treatment or medical care. If you do not wish to receive such communications, please advise us in writing to our listed address in this notice and we will not disclose your information for these purposes.
II. USE AND DISCLOSURE PERMITTED WITHOUT AUTHORIZATION
In certain situations, we may use or disclose your medical information without your needed consent or authorization, subject to all applicable legal requirements or limitations. Examples include the following:
Required by Law – We may use and disclose your medical information when required by federal, state, or local law; including, but not limited to court orders, warrants, and grand jury subpoenas.
Court Orders, Judicial, and Administrative Proceedings - We may use and disclose your medical information to law enforcement officials, medical examiners and coroners, and to the courts or administrative proceedings, as required by law or other legal processes.
Public Health Services – We may use and disclose your medical information when preventing or controlling a disease, injury, or disability, as required by law. We are also authorized by law to disclose information and notify persons who may have been exposed to a communicable disease or at risk of spreading or contracting a disease or condition.
Research Purposes - We may use and disclose your medical information under limited circumstances where the use or disclosure for research has been approved by an institutional review board or privacy board and deemed necessary. Health Oversight Activities – We may use and disclose your medical information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures are necessary for certain state and federal agencies to monitor healthcare systems, government programs, and compliance.
Worker’s Compensation – We may use and disclose your medical information as allowed or required by law relating to worker’s compensation or other similar programs.
Information Not Personally Identifiable – We may use and disclose your medical information if the material is de-identified through the removal of specified identifiers. De-identifiable information does not personally reveal or identify who you are.
Notifications – We may use and disclose your medical information to notify a family member, personal representative, or any person that is listed by you in your patient forms. In the case of an emergency, only the information that is necessary for your treatment will be disclosed according to our professional judgment.
III. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding your medical information at our practice:
Right to Inspect and Copy- You have the right to inspect and obtain a copy of your medical information, with certain limitations subject to law prohibiting access to protected health information, or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceedings.
Right to Amend - You have the right to request an amendment if you feel your medical information is incorrect or incomplete.
Right to Request Restrictions - You have the right to request a restriction on the use and disclosure of your medical information for the purposes of treatment, payment, or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care, or for communication purposes as described in this Notice of Privacy Practices. Your request must be in writing and addressed to our HIPAA Compliance Officer with the provided address listed below for complaints or requests. Please note we are not required to agree to a requested restriction, and will notify you in writing if we approve or deny your request.
IV. REVISIONS TO THIS NOTICE
Cy Fair Pediatrics reserves the right to make revisions to the terms in this Notice at any time, as permitted by law. Patients will be provided a copy of any changes upon request, and may obtain a copy of the current Notice from our office at any time.
We are required by law and regulation to protect the privacy of your medical information and to abide by the terms of the Notice of Privacy Practices in effect. If you are concerned that your privacy rights have been violated, please contact our office with the provided information listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint with us or the government.
For more information about this Notice, or our privacy practices and policies, please contact our office at 832-688-8946 or 281-894-3100
Complaints or requests should be addressed to: Cy Fair Pediatrics
Attn: HIPAA Compliance Officer
3645 Cypress Creek Pkwy, Ste.278
Houston, TX 77068
This notice was published and becomes effective on February 28, 2020
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge receipt of the Notice of Privacy Practices followed by Cy Fair Pediatrics.
By signing below, I hereby acknowledge that I have been given a copy and reviewed this Notice.
Signature of Patient or Legal Representative
Representative’s Relationship to Patient (if applicable)