Effective Date: August 1, 2004
Form # 0649
Date Revised: 08/04

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.

1. Purpose: The Driscoll Children's Hospital and its professional staff, employees, and volunteers and all of its affiliated entities (Children’s Physician Services of South Texas, Driscoll Physicians Group, Driscoll Valley Physicians Group, Driscoll Maternal and Fetal Physicians Group and Driscoll Children's Health Plan) (referred to collectively as Hospital) follow the privacy practices described in this Notice. The Hospital maintains your medical information in records that will be maintained in a confidential manner, as required by law. However, the Hospital must use and disclose your medical information to the extent necessary to provide you with quality health care. To do this, the Hospital must share your medical information as necessary for treatment, payment and health care operations.
   
2. 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. The Hospital may use your medical information as required by your insurer or HMO to obtain payment for your treatment and hospital stay. We also may use and disclose your medical information to improve the quality of care, e.g., for review and training purposes.
   
3. How Will the Hospital Use My Medical Information? Your medical information may be used, unless you ask for restrictions on a specific use or disclosure, for the following purposes:
   

   Hospital Directory, which may include your name, general condition, and your location in the Hospital. Religious affiliation to a hospital chaplain or member of the clergy. Family members or close friends involved in your care or payment for your treatment. Disaster relief agency if you are involved in a disaster relief effort. Appointment reminders. To inform you of treatment alternatives or benefits or services related to your health. (You will have an opportunity to refuse to receive this information.) Fundraising activities by the Hospital’s Foundation, but such information will be limited to your name, address, phone number, and the dates you received services at the Hospital. (You will have an opportunity to refuse to receive these communications.) As required by law. Public health activities, including disease prevention, injury or disability; reporting births and deaths; reporting child abuse or neglect; reporting reactions to medications or product problems; notification of recalls; infectious disease control; notifying government authorities of suspected abuse, neglect or domestic violence (if you agree or as required by law). Alcohol and drug abuse information has special privacy protections. The Hospital will not disclose any information identifying an individual as being a patient or provide any medical information relating to the patient’s substance abuse treatment unless: (i) the patient consents in writing; (ii) a court order requires disclosure of the information; (iii) medical personnel need the information to meet a medical emergency; (iv) qualified personnel use the 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. Health oversight activities, e.g., audits, inspections, investigations, and licensure. Lawsuits and disputes. (We will attempt to provide you advance notice of a subpoena before disclosing the information.) Law enforcement (e.g., in response to a court order or other legal process; to identify or locate an individual being sought by authorities; about the victim of a crime under restricted circumstances; about a death that may be the result of criminal conduct; about criminal conduct that occurred on the Hospital’s premises; and in emergency circumstances relating to reporting information about a crime.) Coroners, medical examiners, and funeral directors. Organ and tissue donation. Certain research projects. To prevent a serious threat to health or safety. To military command authorities if you are a member of the armed forces or a member of a foreign military authority. National security and intelligence activities. Protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations. Inmates. (Medical information about inmates of correctional institutions may be released to the institution.) Workers’ Compensation. (Your medical information regarding benefits for work-related illnesses may be released as appropriate.) To carry out health care treatment, payment, and operations functions through business associates, e.g., to install a new computer system.

4. Your Authorization Is Required for Other Disclosures. Except as described above, we will not use or disclose your medical information unless you authorize (permit) the Hospital in writing to disclose your information. You may revoke your permission, which will be effective only after the date of your written revocation.
   
5. You Have Rights Regarding Your Medical Information. You have the following rights regarding your medical information, provided that you make a written request to invoke the right on the form provided by the Hospital:
   

   Right to request restriction. You may request limitations on your medical information we use or disclose for health care treatment, payment, or operations (e.g., you may ask us not to disclose that you have had a particular surgery), but we are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment. Right to confidential communications. You may request communications 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 to request and receive a copy of your medical information regarding decisions about your care; however, psychotherapy notes may not be inspected and copied. We may charge a fee for copying, mailing and supplies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed health care professional chosen by the Hospital. The Hospital will comply with the outcome of the review. Right to request amendment. If you believe that the medical information we have about you is incorrect or incomplete, you may request an amendment on the form provided by the Hospital, which requires certain specific information. The Hospital is not required to accept the amendment. Right to accounting of disclosures. You may request a list of the disclosures of your medical information that have been made to persons or entities other than for health care treatment payment or operations in the past six (6) years, but not prior to April 14, 2003. After the first request, there may be a charge. Right to a copy of this Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. You may obtain an electronic copy of this Notice at our web site, http://www.driscollchildrens.org.

6. Requirements Regarding This Notice. The Hospital is required by law to provide you with this Notice. We will be governed by this Notice for as long as it is in effect. The Hospital may change this Notice and these changes will be effective for medical information we have about you as well as any information we receive in the future. Each time you register at the Hospital for health care services as an inpatient or outpatient, you may receive a copy of the Notice in effect at the time.
   
7. Complaints. If you believe your privacy rights have been violated, you may file a complaint with the Hospital or with the Secretary of the United States Department of Health and Human Services. You will not be penalized or retaliated against in any way for making a complaint to the Hospital or the Department of Health and Human Services.

Contact: Call Aaron Childress at 361-694-6720 if you:

• have a complaint;
• have any questions about this Notice;
• wish to request restrictions on uses and disclosures for health care treatment, payment, or operations; or
• wish to obtain a form to exercise your individual rights described in paragraph 5.