NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

This notice describes how your medical information can be used and disclosed and how you can get access to this information. Please review it carefully.

Houston Women's Clinic is committed to protecting the privacy of your medical records and the confidentiality of your visit. Your records (chart) will not be released to anyone outside of this facility with out your written permission unless a release is required by law.

We will use your information for the following purposes:
1. Treatment - to determine your care and treatment
2. Payment - if using insurance we will release information necessary for billing
3. Regular Healthcare Operations - members of the staff may review your records as part of our quality assurance
4. Business Associates - if a billing/collection service is used (we do not use any such service at this time).

Disclosure required by law:
1. Food and Drug Administration (FDA) - if there were a drug/product recall or defect
2. Public Health - we may disclose your health information, to public health authorities in charge of controlling disease, injury or disability.
3. Law Enforcement - we may disclose health information in response to a valid subpoena.

YOUR HEALTH INFORMATION RIGHTS
Your health record is the physical property of the clinic but the information belongs to you and you have the right to the following:
1. Request a restriction on certain uses and disclosures of your information
2. Obtain a copy of the notice of information practices (this document)
3. Inspect a copy of your health records
4. Amend your health record as provided in 45 CFR 164.528
5. Obtain an accounting of disclosures of your health information
6. Request communication of your health information by alternative means or at alternative locations
7. Revoke your authorization to use or disclose health information except for action already taken.

OUR RESPONSIBILITY
We are required to:
1. Maintain the privacy of your information
2. Provide you with a notice that explains our legal duties and privacy practices
3. Abide by the terms of this notice
4. Notify you if we are unable to agree to a restriction that you request
5. Accommodate reasonable requests you may have to communicate health information by alternative means or locations. We reserve the right to change practices and make new provisions.

FOR MORE INFORMATION OR TO REPORT A PROBLEM
For questions or problems, our privacy officer is Bernard Rosenfeld, M.D. at 713-868-4483. Complaints may also be filed with the Secretary of Health and Human Services, with no retaliation.

I have read this privacy notice and have been given time for questions.

I understand Houston Women's Clinic will not release my health information unless I give written permission or when required by law.


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Notice Effective Date 04-14-03