Notice of Privacy Practices

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.

Our responsibilities

Adeline Memorial Medical Group is required by law to maintain the privacy and security of your protected health information (“PHI”), to give you this notice of our legal duties and privacy practices, to follow the terms of the notice currently in effect, and to notify you if a breach occurs that may have compromised the privacy or security of your information. We will not use or share your information other than as described here unless you tell us we can in writing. You may change your mind at any time by letting us know in writing.

How we may use and share your health information

Treatment. We use and share your information with other professionals who are treating you — for example, a specialist, laboratory, pharmacy, or hospital.

Payment. We use and share your information to bill and get payment from health plans or other entities.

Health care operations. We use and share your information to run our practice, improve your care, train staff, and contact you when necessary.

Appointment reminders and health-related services. We may contact you by phone, mail, email, or text message (if you have agreed) about appointments, results, or treatment options.

Other uses and disclosures

We are allowed or required to share your information in other ways — usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes:

• Public health and safety, such as preventing disease, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety
• Research, under conditions required by law
• As required by law, including to the U.S. Department of Health and Human Services if it wants to see that we are complying with federal privacy law
• Organ and tissue donation requests
• Medical examiners or funeral directors
• Workers’ compensation, law enforcement, and other government requests, including health oversight agencies and special government functions such as military, national security, and presidential protective services
• Lawsuits and legal actions, in response to a court or administrative order or a subpoena

Uses that require your written authorization

We will never share your information for marketing purposes, sell your information, or share most psychotherapy notes unless you give us written permission. Records of substance use disorder treatment from federally assisted programs and certain other sensitive information may receive additional protection under federal and Texas law.

Your choices

For certain health information, you can tell us your choices about what we share. You have both the right and choice to tell us to share information with your family, close friends, or others involved in your care, or in a disaster relief situation. If you are not able to tell us your preference — for example, if you are unconscious — we may share your information if we believe it is in your best interest.

Your rights

• Get a copy of your health and claims records. You can ask to see or get an electronic or paper copy of your medical record. We will provide a copy or summary, usually within 15 days of your request as required by Texas law. We may charge a reasonable, cost-based fee.
• Ask us to correct your medical record if you think it is incorrect or incomplete. We may say “no,” but we will tell you why in writing within 60 days.
• Request confidential communications — for example, by contacting you at a different phone number or address. We will say “yes” to all reasonable requests.
• Ask us to limit what we use or share. We are not required to agree, except that if you pay for a service or item out of pocket in full, you can ask us not to share that information with your health insurer for payment or operations.
• Get a list of those with whom we’ve shared information for six years prior to the date you ask, with certain exceptions.
• Get a copy of this notice on paper at any time, even if you agreed to receive it electronically.
• Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.
• File a complaint if you feel your rights are violated (see below).

Texas privacy protections

Texas law provides additional protections for your health information, including limits on electronic disclosure of PHI. We will provide notice and obtain your authorization for electronic disclosures when required by Texas Health and Safety Code Chapter 181.

How to file a complaint

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer at info@ammgmedicine.com or 713-981-5166. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue SW, Washington, DC 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/complaints. We will not retaliate against you for filing a complaint.

Changes to this notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our offices, and on our website.

Effective date

This notice is effective as of the date shown at the top of this page.