NOTICE OF PRIVATE POLICIES

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.

At Gastroenterology Associates of Texas, we are committed to treating and using protected health information about you responsibly. This Notice of Privacy describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Understanding Your Health Record/Information
Each time you visit Gastroenterology Associates of Texas, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care treatment. This information, often referred to as your health or medical record, serves as a:

• Basis for planning your care and treatment,

• Means of communication among the many health professionals who contribute to your care,

• Legal document describing the care you received,

• Means by which you or a third-party payer can verify that services billed were actually provided,

• A tool in educating health professionals,

• A source of data for medical research,

• A source of information for public health officials charged with improving the health of this state and the nation,

• A source of data for our planning and marketing,

• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights
Although your health record is the physical property of Gastroenterology Associates of Texas, the information belongs to you. You have the right to:

• Obtain a paper copy of this notice of information practices upon request,

• Inspect and copy your health record,

• Amend your health record,

• Obtain an accounting of disclosures of your health information,

• Request communications of your health information by alternative means or at alternative locations,

• Request a restriction on certain uses and disclosures of your information,

• Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Our Responsibilities
Gastroenterology Associates of Texas is required to:

• Maintain the privacy of your health information,

• Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you,

• Abide by the terms of this notice,

• Notify you if we are unable to agree to a requested restriction, and

• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us, or if you agree, we will email the revised notice to you.
We will not use or disclosed your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.

For More Information or to Report a Problem
If you have questions and would like additional information, you may contact the practice’s Privacy Officer (713) 574-6220.
If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is listed below:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201

Examples of Disclosures for Treatment, Payment and Health Operations
We will use your health information for treatment.

For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of the health care team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.
We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you’re discharged from this hospital.

We will use your health information for payment.

For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

We will use your health information for regular health operations.

For example: Members of the medical staff, the risk or quality improvement manager, or member, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Business Associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general
condition.

Community with Family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physician or another physician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.

Communication Barriers: We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health: As required by law, we may disclose your health information to public health or legal authorities charge with preventing or controlling disease, injury, or disability.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent
such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend and individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

Notice of Privacy Policies Revision Number 0001

PATIENT RIGHTS

This form is meant to inform you, the patient, as well as your family that you have rights and responsibilities while undergoing medical care. If there are any questions regarding the contents of this form please notify any staff member.

Patient Rights

1. Access to Care – Individuals shall be accorded impartial access to treatment or accommodations as to his or her requests and needs for treatment or service that are within the clinic’s capacity, availability, stated mission and applicable law and regulation, regardless of race, creed, sex, national origin, religion, disability/handicap or source of payment of care/services;

2. Respect and Dignity – Every individual, whether adult, adolescent or newborn, has the right to considerate, respectful care/services at all times and under all circumstances, with recognition of his or her personal dignity an his or her psychosocial, spiritual and cultural variables that influence the perceptions of illness.

3. Privacy and Confidentiality – The patient or his or her parent or legally designated representative has the right, within the law, to personal and informational privacy, as manifested by the right to:

• Wear appropriate personal clothing and religious or other symbolic items, as long as they do not interfere with diagnostic procedures or treatment.

• Be interviewed and examined in surroundings designed to assure reasonable audiovisual privacy. This includes the right to have a person of one’s own sex present during certain parts of a physical
examination, treatment or procedure performed by a health professional of the opposite sex and the right not to remain disrobed any longer than is required for accomplishing that medical purpose for which the patient was asked to disrobe.

• Expect that any discussion or consultation involving the patient’s case – whether the patient is an adult, adolescent or newborn – will be conducted discreetly, and that individuals not directly involved in his or her care/services will not be present without his/her permission.

• Have the right to review his or her medical records and have the information explained, except when restricted by law.

• Have the medical records read only by individuals directly involved in the treatment or the monitoring of its quality and by other individuals only on the patient’s or his or her parent or legal designated representative’s written authorization.

• Expect all communications and other records pertaining to care/services of the individual, including the source of payment for treatment, to be treated as confidential.

•Request a transfer to another treatment room if another patient or visitor is unreasonably disturbing him.

• Be placed in protective privacy when considered necessary for personal safety.

4. Personal Safety – The patient, whether adult, adolescent or newborn, has the right to expect reasonable safety insofar as the clinic practices and environment are concerned.

5. Identity – The patient or his or her parent or legally designated representative has the right to know the identity and professional status of individuals providing service to the patient, and to know
which physician or other practitioner is primarily responsible for his or her care/services. This includes the right to know of the existence of any professional relationship among individuals who are treating him or her, as well as the relationship of the clinic to any other health care/services or educational institution involved in his or her care/services. Participation by patients in clinical training programs or in the gathering of data for research purposes should be voluntary.

6. Information – The patient or his or her parent or legally designated representative has the right to obtain from the practitioner responsible for coordination of his or her care/services complete and current information concerning his or her diagnosis (to the degree known), treatment and any known prognosis. This information should be communicated in terms the patient or his or her parent or legal designated representative can reasonably be expected to understand. When it is not medically advisable to give such information to the patient, the information should be made available to a legally authorized individual.

7. Communication – The patient or his or her parent or legally designated representative has the right of access to people outside the clinic by means of visitors and by verbal and written communication. When the patient or his or her parent or legally designated representative does not speak or understand the predominant language of the community, he or she should have access to an interpreter. This is particularly true where language barriers are a continuing problem.

8. Consent – The patient or his or her parent or legally designated representative has the right to the information necessary to enable him or her, in collaboration with the health care practitioner, to make treatment decisions involving his or her health care/services that reflect his or her wishes. To the degree possible, this should be based on a clear, concise explanation of his or her condition and all proposed technical side effects, problems related to recuperation, and probability of success. The patient should not be subjected to any procedure without voluntary, competent and understanding consent by the individual or by his or her parent or legal designated representative. Where a medically significantly need for care/services or treatment exists, the patient or his or her parent or legal designated representative shall be so informed.

• The patient or his or her parent or legally designated representative has the right to know who is responsible for authorizing and performing the procedures or treatment.

• The patient or his or her parent or legally designated representative shall be informed if the clinic proposes to engage in or perform human experimentation or other research/educational projects affecting his or her care/services or treatment, and the patient has the right to participate in any such activity. If the patient chooses not to take part, he or she shall receive the most effective care/services the clinic otherwise provides.

9. Consultation – The patient or his or her parent or legally designated representative has the right to accept medical care/services or to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal. When refusal of treatment by the patient or his or her parent or legal designated representative prevents the provision of appropriate care/services in accordance with ethical and professional standards, the relationship with the patient may be terminated upon reasonable notice.

10. Transfer and Continuity of Care – A patient has the right to expect that the clinic/facility will give necessary health services to the best of its ability. Treatment, referral or transfer may be recommended. If transfer is recommended or requested, the patient will be informed of risks, benefits and alternatives. The patient will not be transferred until the other institution agrees to accept such patient.

11. Charges – Regardless of the source of payment for the individual’s care/services, the patient or his or her parent or legal designated representative has the right to request and receive an itemized and detailed explanation of his or her total bill for services rendered in the clinic. The patient has the right to timely notice prior to termination of his or her eligibility for reimbursement by any third-party payer for the cost of his or her care/services.

12. Delineation of Patient’s Rights – The rights of the patient may be delineated on behalf of the patient, to the extent permitted by law, to the patient’s guardian, next of kin or legally authorized responsible person if the patient:

• Has been adjudicated incompetent in accordance with the law.

• Is found by his or her physician to be medically incapable of understanding the proposed treatment or procedure.

• Is unable to communicate his or her wishes regarding treatment.

• Is a minor.

13. Rules and Regulations – The patient or his or her parent or legally designated representative should be informed of the clinic rules and regulations applicable to his or her conduct as a patient. Patients are entitled to information about the mechanism for the initiation, review and resolution of patient complaints.

PATIENT RESPONSIBILITIES

This form is meant to inform you, the patient, as well as your family that in addition to rights, you have responsibilities while undergoing medical care. If there are any questions regarding the contents of this form please notify any staff member.

1. Keep Your Health Care Providers Accurately Informed – A patient or his or her parent or legally designated representative has the responsibility to provide, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to his or her health. He or she has the responsibility to report unexpected changes in his or her condition to the responsible for making it known whether he or she comprehends a contemplated course of action and what is expected of him.

2. Follow Your Treatment Plan – A patient or his or her parent or legally designated representative is responsible for following the treatment plan recommended by the practitioner primarily responsible for the patient’s care/services. This may include following the instructions of health care personnel as they carry out the coordinated plan of care/services and implement the responsible practitioner’s orders and as they enforce the applicable clinic rules and regulations.

3. Keep Your Appointments – The patient is responsible for keeping appointments and, when unable to do so for any reason, for notifying the responsible practitioner or the clinic.

4. Be Responsible For Any Decision You Make Not To Follow Your Treatment Plan, And Keep Your Health Care Practitioners Informed About Your Decision(s) – The patient or his or her parent or legally designated representative is responsible for his or her actions if he or she refuses treatment or does not follow the practitioner’s instructions. If the patient cannot follow through with the treatment, he or she is responsible for informing the physician.

5. Be Responsible For Your Financial Obligations – The patient or his or her parent or legally designated representative is responsible for assuring that the financial obligations of his or her health care/services are fulfilled as promptly as possible. The patient is responsible for providing information for insurance.

6. Comply With The Rules Of This Facility Regarding Patient Care and The Conduct of Our Clients/Visitors – The patient or his or her parent or legally designated representative is responsible for following clinic rules and regulations affecting patient care/services and conduct.

7. Be Considerate of Others – The patient or his or her parent or legally designated representative is responsible for being considerate of the rights of other patients and personnel, and for assisting in the control of noise, smoking and the number of visitors. The patient is responsible for being respectful of the property of others and of the clinic.

8. Be Responsible For Your Own Lifestyle Choices – A patient’s health depends not just on his or her care/services but, in the long term, on the decisions he or she makes in daily life. He or she is responsible for recognizing the effect of lifestyle on his or her personal life.