HEALTH eLOOKS, LLC
d/b/a Colleyville Medical Clinic
Effective Date: April 14,2003
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.
We understand and respect that information about you and your health is personal. By law, Colleyville Medical Clinic is required to maintain the privacy of your health information, to follow the terms of this Notice, and to provide you with this notice of our legal duties and privacy practices with respect to your health information. For your convenience, you may print a paper copy of this notice for your records at any time.
How Colleyville Medical Clinic May Use or Disclose Your Health Information
Colleyville Medical Clinic protects the privacy of your health information. For some activities, we must have your written authorization to use or disclose your health information. However, the law permits Colleyville Medical Clinic to use or disclose your health information for the following purposes without your authorization:
As Required by Law: We will disclose health information about you when required to do so by Federal and State Law.
To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would be only to a person or agency able to help prevent the threat.
Public Health Risks: We may disclose health information about you for public health activities. Those activities generally include the following: (1) to prevent or control disease, injury or disability; (2) to report reactions to medications or problems with products; (3) to notify people of product recalls; (4) to notify a person that may be exposed to a disease or may be at risk of spreading a disease; (5) to notify the appropriate government authority if we believe a person has been the victim of abuse, neglect, or domestic violence.
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law.
Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court or administrative order. We may disclose information about you in response to a subpoena, or other lawful process, but only if efforts have been made to tell you about the request.
For Specific Government Functions: We may disclose health information for the following specific government functions (1) health information of military personnel, as required by military authorities ; (2) health information of inmates to a correctional institution or law enforcement official; (3) in response to a request from law enforcement, if certain conditions are satisfied; and (4) for national security reasons.
For Treatment: Information obtained by Colleyville Medical Clinic may be shared or communicated with your physician and/or other health care professionals who are involved in your care.
For Company Operations: We may use and disclose health information about you for company operations.
Unless you provide us with alternative instructions, we may send reminders and other materials related to your health care to your home. These uses and disclosures are necessary to ensure that you receive quality service.
When Colleyville Medical Clinic May NOT Use or Disclose Your Health Information
Except as described in the Notice, Colleyville Medical Clinic will not use or disclose your health information
without your written authorization. If you do authorize Colleyville Medical Clinic to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
You Have the Following Rights With Respect to Your Health Information
You have the right to request restrictions on certain uses and disclosures of your health information. We are not required to agree to the restrictions that you request. If we do agree to any restrictions, we will put the agreement in writing and follow it except in emergency situations. We cannot agree to limit the disclosure of any information that is required by law.
You have the right to inspect and copy your health information as long as Colleyville Medical Clinic maintains the health information. To inspect a copy of your records, you must submit a request in writing. We may charge a fee for the costs of copying, mailing, or supplies necessary to grant your request. In certain limited situations, we may deny your request. If your request is denied, you may request that the denial be reviewed.
You have the right to request that we amend or correct any health information that is incorrect or incomplete. To request an amendment, you must submit a request in writing along with the reason for the request. We are not required to amend health information that is accurate and complete.
You have the right to receive an accounting of disclosure of your health information we have made after April 14, 2003 for purposes other than disclosures for (1) payment, treatment, or health care operations ; (2) to you or based upon your authorization; or (3) for certain government functions. You must submit your request in writing.
You may request communication of your health information by alternative means or at alternative locations. You may request that we contact you only in writing or at a different residence or post office box. To request confidential communication of your health information, you must submit a written request. We will accommodate all reasonable requests.
Changes to this Notice of Privacy Practices
Colleyville Medical Clinic reserves the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. Any revised Notice will be posted at the business and posted on our website. Upon request we will provide a revised Notice to you or you may print one for your records.
For More Information or to Report a Problem
If you have questions or would like additional information about our company's privacy practices, you may write:
Colleyville Medical Clinic
6400 Colleyville Blvd.
Colleyville, TX 76034
or by email to: email@example.com. If you believe your privacy rights have been violated, you can file a complaint with the Compliance Officer at the above address, or with the Secretary of Health and Human Services.
There will be no retaliation for filing a complaint.