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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.

 

Who Presents this Notice?

 

This Notice describes the privacy practices of Preston Family Healthcare and members of its workforce, as well as the
physician members of the medical staff and allied health professionals who practice at the Practice. The Practice and the
individual health care providers together are sometimes called "the Practice and Health Professionals" in this Notice.
While the Practice and Health Professionals engage in many joint activities and provide services in a clinically integrated
care setting, the Practice and Health Professionals each are separate legal entities. This Notice applies to services
furnished to you at the Practice as a Practice patient or any other services provided to you in a Practice-affiliated
program involving the use or disclosure of your health information.

 

Privacy Obligations

 

The Practice and Health Professionals are each required by law to maintain the privacy of your health information
Protected Health Information" or "PHI") and to provide you with this Notice of legal duties and privacy practices with respect to your Protected Health Information. The Practice and Health Professionals use computerized systems that may
subject your Protected Health Information to electronic disclosure for purposes of treatment, payment and/or health
care operations as described below. When the Practice and Health Professionals use or disclose your Protected Health
Information, the Practice and Health Professionals are required to abide by the terms of this Notice (or other notice in
effect at the time of the use or disclosure).

 

Permissible Uses and Disclosures Without Your Written Authorized

 

In certain situations, your written authorization must be obtained in order to use and/or disclose your PHI. However, the
Practice and Health Professionals do not need any type of authorization from you for the following uses and disclosures:

 

Uses and Disclosures for Treatment, Payment and Health Care Operations. Your PHI, may be used and disclosed to
treat you, obtain payment for services provided to you and conduct "health care operations" as detailed below:
Treatment. Your PHI may be used and disclosed to provide treatment and other services to you--for example, to
diagnose and treat your injury or illness. In addition, you may be contacted to provide you with appointment reminders
or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

 

Your PHI may also be disclosed to other providers involved in your treatment. For example, a doctor treating you for a
broken leg may need to know if you have diabetes because if you do, this may impact on your recovery.

 

Payment. Your PHI may be used and disclosed to obtain payment for services provided to you--for example, disclosures
to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some
or all of your health care ("Your Payor") to verify that Your Payor will pay for health care. The physician who reads your
x-ray may need to bill you or your Payor for reading of your x-ray therefore your billing information may be shared with
the physician who read your x-ray.

 

Health Care Operations. Your PHI may be used and disclosed for health care operations, which include internal
administration and planning and various activities that improve the quality and cost effectiveness of the care delivered
to you. For example, PHI may be used to evaluate the quality and competence of physicians, nurses, and other health
care workers. PHI may be disclosed to the Practice Compliance & Privacy Office in order to resolve any complaints you
may have and ensure that you have a comfortable visit. Your PHI may be provided lo various governmental or

 

NOTICE OF PRIVACY PRACTICES

 

Accreditation entities such as the Joint Commission on Accreditation of Healthcare Organizations to maintain our license
and accreditation. In addition, PHI may be shared with business associates who perform treatment, payment, and health
care operations services on behalf of the Practice and Health Professionals.

 

Use or Disclosure for Directory of Individuals in the Practice. The Practice may include your name, location in the
Practice, general health condition and religious affiliation in a patient directory without obtaining your authorization
unless you object to inclusion in the directory. Information in the directory may be disclosed to anyone who asks for you
by name. Your religious affiliation may be given to a member of the clergy, such as a priest or minister, even if they do
not ask for you by name. If you do not wish to be included in the facility directory, you will be given an opportunity to
object at the time of admission.

 

Disclosure to Relatives. Close Friends and Other Caregivers. Your PHI may be disclosed to a family member, other
relative, a close personal- friend or any other person identified by you who is involved in your health care or helps pay
for your care. If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be
provided because of your incapacity or an emergency circumstance, the Practice and/or Health Professionals may
exercise professional judgment to determine whether a disclosure is in your best interests. If information is disclosed to
a family member, other relative or a close personal friend, the Practice and/or Health Professionals would disclose only
information believed to be directly relevant to the person's involvement with your health care or payment related to
your health care. Your Pill also may be disclosed in order to notify (or assist in notifying) such persons of your location or

general condition.

 

Public Health Activities. Your PHI may be disclosed for the following public health activities: (I) to report health
information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to
report child abuse and neglect to public health authorities or other government authorities authorized by law to receive
such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug
Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at
risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under
laws addressing work-related illnesses and injuries or workplace medical surveillance.

 

Victims of Abuse. Neglect or Domestic Violence. Your PHI may be disclosed to a governmental authority, including a
social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic
violence if there is a reasonable belief that you are a victim of abuse, neglect or domestic violence.
Health Oversight Activities. Your PHI may be disclosed to a health oversight agency that oversees the health care
system and is charged with responsibility for ensuring compliance with the rules of government health programs such as

 

Medicare or Medicaid.

 

Judicial and Administrative Proceedings. Your PHI may be disclosed in the course of a judicial or administrative
proceeding in response to a legal order or other lawful process.

 

Law Enforcement Officials. Your PHI may be disclosed to the police or other law enforcement officials as required or
permitted by law or in compliance with a court order or a grand jury or administrative subpoena. For example, your PHI
may be disclosed to identify or locate a suspect, fugitive, material witness, or missing person or to report a crime or
criminal conduct at the facility.

 

Correctional Institution. You PHI may be disclosed to a correctional institution if you are an inmate in a correctional
institution and if the correctional institution or law enforcement authority makes certain requests to us.

 

NOTICE OF PRIVACY PRACTICES

 

Business Associates. Your PHI may be disclosed to business associates or third parties that the Practice and Health
Professionals have contracted with to perform agreed-upon services.

 

Decedents. Your PHI may be disclosed to a coroner or medical examiner as authorized by law.

 

Organ and Tissue Procurement. Your PHI may be disclosed to organizations that facilitate organ, eye or tissue
procurement, banking, or transplantation.

 

Research. Your PHI may be used or disclosed without your consent or authorization if an Institutional Review Board
approves a waiver of authorization for disclosure.

 

Health or Safety. Your PHI may be used or disclosed to prevent or lessen a serious and imminent threat to a person's or
the public's health or safety.

 

Specialized Government Functions. Your PHI may be disclosed to units of the government with special functions, such
as the U.S. military, the U.S. Department of State under certain circumstances such as the Secret Service or NSA to
protect, for example, the country or the President.

 

Worker' Compensation. Your PHI may be disclosed as authorized by and to the extent necessary to comply with state
law relating to workers' compensation or other similar programs.

 

As Required by Law. Your PHI may be used and disclosed when required to do so by any other law not already referred
to in the preceding categories, such as required by the FDA, to monitor the safety of a medical device.

 

Appointment Reminders. Your PHI may be used to tell or remind you about appointments.
Fundraising. Your PHI may be used to contact you as a part of fundraising efforts unless you elect not to receive this
type of information.

 

USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

 

Use or Disclosure with Your Authorization. For any purpose other than the ones described above, your PHI may be used
or disclosed only when you provide your written authorization on an authorization form ("Your Authorization"). For
instance, you will need to execute an authorization form before your PHI can be sent to your life insurance company or
to the attorney representing the other party in litigation in which you are involved.

 

Marketing. Your written authorization ("Your Marketing Authorization") also must be obtained prior to using your PHI to
send you any marketing materials. (However, marketing materials can be provided to you in a face-to-face encounter
without obtaining Your Marketing Authorization. The Practice and/or Health Professionals are also permitted to give you
a promotional gift of nominal value, if they so choose, without obtaining Your Marketing Authorization).The Practice
and/or Health Professionals may communicate with you in a face-to-face encounter about products or services relating
to your treatment, case management or care coordination, or alternative treatments, therapies, providers, or care
settings without Your Marketing Authorization.

 

In addition, the Practice and/or Health Professionals may send you treatment communications, unless you elect not to
receive this type of communication, for which the Practice and/or Health Professionals may receive financial
remuneration.

 

Sale of PHI. The Practice and Health Professionals will not disclose your PHI without your authorization in exchange for
direct or indirect payment except in limited circumstances permitted by law. These circumstances include public health
activities; research; treatment of the individual; sale, transfer, merger or consolidation of the Practice; services provided

 

NOTICE OF PRIVACY PRACTICES

 

by a business associate, pursuant to a business associate agreement; providing an individual with a copy of their PHI;
and other purposes deemed necessary and appropriate by the U.S. Department of Health and Human Services (HHS).

 

Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law require special privacy
protections for certain highly confidential information about you ("Highly Confidential Information"), including the
subset of your PHI that: (I) is maintained in psychotherapy notes; (2) is about mental illness, mental retardation and
developmental disabilities; (3) is about alcohol or drug abuse or addiction; ( 4) is about HIV/ AIDS testing, diagnosis or
treatment; (5) is about communicable disease(s), including venereal disease(s); (6) is about genetic testing; (7) is about
child abuse and neglect; (8) is about domestic abuse of an adult; or (9) is about sexual assault. For your Highly
Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization is
required.

 

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

 

Right to Request Additional Restrictions. You may request restrictions on the use and disclosure of your PHI (I) for
treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close
personal friend or any other person identified by you) involved with your care or with payment related to your care, or
(3) to notify or assist in the notification of such individuals regarding your location and general condition. While all
requests for additional restrictions will be carefully considered, the Practice and Health Professionals are not required to
agree to these requested restrictions.

 

You may also request to restrict disclosures of your PHI to your health plan for payment and healthcare operations
purposes (and not for treatment) if the disclosure pertains to a healthcare item or service for which you paid out-of-
pocket in full. The Practice and Health Professionals must agree to abide by the restriction on your health plan EXCEPT
when the disclosure is required by law.

 

If you wish to request additional restrictions, please obtain a request form from the Practice, and submit the completed
form to the Practice. A written response will be sent to you.
Right to Receive Confidential Communications. You may request, and the Practice and Health Professionals will
accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at
alternative locations.

 

Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any written
authorization obtained in connection with your PHI, except to the extent that the Practice and/or Health Professionals
have taken action in reliance upon it, by delivering a written revocation statement to the Practice identified below.
Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing
records maintained by the Practice and Health Professionals in order to inspect and request copies of the records. Under
limited circumstances, you may be denied access to a portion of your records. If you desire access to your records,
please obtain a record request form from the Practice and submit the completed form to the Practice. If you request
copies of paper records, you will be charged in accordance with federal and state law. To the extent the request or
records includes portions of records which are not in paper form (e.g., x-ray films), you will be charged the reasonable
cost of the copies. You also will be charged for the postage costs, if you request that the copies be mailed to you.
However, you will not be charged for copies that are requested in order to make or complete an application for a federal
or state disability benefits program.

 

NOTICE OF PRIVACY PRACTICES

 

Right to Amend Your Records. You have the right to request that PHI maintained in your medical record file or billing
records be amended. If you desire to amend your records, please obtain an amendment request form from the Practice
and submit the completed form to the Practice. Your request will be accommodated unless the Practice and/or Health

Professionals believe that the information that would be amended is accurate and complete or other special
circumstances apply.

 

Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of
your PHI made during any period of time prior to the date of your request provided such period does not exceed six
years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than
once during a twelve (12) month period, you will be charged for the accounting statement.

Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have
agreed to receive such notice electronically.

 

For Further Information or Complaints. If you desire further information about your privacy rights, are concerned that
your privacy rights have been violated or disagree with a decision made about access to your PHI, you may contact the
Practice Compliance & Privacy Office. You may also file written complaints with the Director, Office for Civil Rights of the
U.S. Department of Health and Human Services. Upon request, the Practice Compliance & Privacy Office will provide you
with the correct address for the Director. The Practice and Health Professionals will not retaliate against you if you file a
complaint with the Practice Privacy Office or the Director.

 

Effective Date and Duration of This Notice

 

Effective Date. This Notice is effective on April 20, 2020.

 

Right to Change Terms of this Notice. The terms of this Notice may be changed at any time. If this Notice is changed, the
new notice terms may be made effective for all PHI that the Practice and Health Professionals maintain, including any
information created or received prior to issuing the new notice. If this Notice is changed, the new notice will be posted
in waiting areas around the Practice and on the internet at www.cimwdfw.com. You also may obtain any new notice by
contacting the Practice Compliance & Privacy Office.

 

PRACTICE CONTACTS:

Preston Family Healthcare, PLLC
205 S Preston Rd, Ste. 110, Celina TX 7S009-3763
Phone: 972-382-8520 Fax: 972-382-8568
Practice Manager: Sandra Barboza, Practice Office Manager
E-mail: info@prestonfamilyhealthcare.com