HIPAA NOTICE OF PRIVACY PRACTICES
Effective 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.
Under the Health Insurance Portability and Accountability
Act of 1996 (" HIPAA") we are required to maintain the privacy of
your protected health information and provide you with notice of our legal
duties and privacy practices with respect to such protected health information.
We are required to abide by the terms of the notice
currently in effect. We reserve the right to change the terms of our notice at
any time and to make the new notice provisions effective for all protected
health information that we maintain. In the event that we make a material
revision to the terms of our notice, you will receive a revised notice within
60-days of such revision. If you should have any questions or require further
information, please contact our Privacy Officer at (817) 479-2100 or toll free
at (888) 308-7320.
How We May Use or Disclose Your Health Information
The following describes the purposes for which we are
permitted or required by law to use or disclose your health information without
your consent or authorization. Any other uses or disclosures will be made only
with your written authorization and you may revoke such authorization in
writing at any time.
Treatment: We may use or disclose your health information to
provide you with medical treatment or services. For example, information obtained
by a provider providing health care services to you will record such
information in your record that is related to your treatment. This information
is necessary to determine what treatment you should receive. Health care
providers will also record actions taken by them in the course of your
treatment and note how you respond.
Payment: We may use or disclose your health information in
order to process claims or make payment for covered services you receive under
your benefit plan. For example, your provider may submit a claim to us for
payment. The claim form will include information that identifies you, your
diagnosis, and treatment or supplies used in the course of treatment.
Health Care Operations: We may use or disclose your health
information for health care operations. Health care operations include, but not
limited to, quality assessment and improvement activities, underwriting,
premium rating, management and general administrative activities. For example,
members of our quality improvement team may use information in your health
record to assess the quality of care that you receive and determine how to
continually improve the quality and effectiveness of the services we provide.
Business Associates: There may be instances where services are
provided to our organization through contracts with thirdparty
"business associates". Whenever a business associate arrangement
involves the use or disclosure of your health information, we will have a
written contract that requires the business associate to maintain the same high
standards of safeguarding your privacy that we require of our own employees and
Required by Law: We will disclose
medical information about you when required to do so by federal, state or local
Communication with Family or Friends: Our service
professionals, using their best judgement, may disclose to a family member,
other relative, close personal friend, or any other person you identify, health
information relevant to that person's involvement in your care or payment
related to your care.
Marketing: We may use or disclose
your health information, as necessary, to provide you with information about
treatment alternatives or other health-related benefits and services that may
be of interest to you.
Research: We may disclose information to researchers when their
research has been approved by an institutional review board that has reviewed
the research proposal and established protocols to ensure the privacy of your
Coroners, Medical Examiners and Funeral Directors: We may
disclose health information to a coroner or medical examiner. We may also
disclose medical information to funeral directors consistent with applicable
law to carry out their duties.
Organ Procurement Organizations: Consistent with applicable
law, we may disclose health information to organ procurement organizations or
other entities engaged in the procurement, banking, or transplantation of
organs for the purpose of tissue donation and transplant.
Fund Raising: We may contact you as
part of a fund-raising effort.
Public Health: As required by law, we may disclose your health
information to public health or legal authorities charged with preventing or
controlling disease, injury or disability.
Food and Drug Administration (FDA): We may disclose to the FDA
health information relative to adverse events with respect to food,
supplements, product and product defects, or post marketing surveillance
information to enable product recalls, repairs, or replacement.
Workers' Compensation: We may disclose health information to
the extent authorized by and to the extent necessary to comply with laws
relating to workers compensation or other similar programs established by law.
To Avert a Serious Threat to Health or Safety: Consistent with
applicable federal and state laws, we may use and disclose health information
when necessary to prevent a serious threat to your health and safety or the
health and safety of the public or another person.
Military and Veterans: If you are a member of the armed forces,
we may disclose health information about you as required by military command.
Health Oversight Activities: We may disclose health information
to a health oversight agency for activities authorized by law, including
audits, investigations, inspections, and licensure.
Protective Services for the President, National Security and
Intelligence Activities: We may disclose health information about you
to authorized federal officials so they may provide protection to the
President, other authorized persons or foreign heads of state or conduct
special investigations, or for intelligence, counterintelligence, and other
national security activities authorized by law.
Law Enforcement: We may disclose health information when
requested by a law enforcement official as part of law enforcement activities;
investigations of criminal conduct; in response to court orders; in emergency
circumstances; or when required to do so by law.
Inmates: We may disclose health information about an inmate of
a correctional institution or under the custody of a law enforcement official
to the correctional institution or law enforcement official.
Lawsuits and Disputes: We may disclose health information about
you in response to a subpoena, discovery request, or other lawful order from a
Plan Sponsors: We may disclose health information about you to
your plan sponsor to carry out plan administration functions that the plan
sponsor performs upon certification by the plan sponsor that the plan documents
have been amended as set forth under HIPAA regulations.
Your Rights Regarding Your Health Information
The following describes your rights regarding the health
information we maintain about you. To exercise your rights, you must submit
your request in writing to our Privacy Officer at 1005 Glade Road,
Right to Request Restrictions. You
have the right to request that we restrict uses or disclosures of your health
information to carry out treatment, payment, health care operations, or
communications with family or friends. We are not required to agree to a
Right to Receive Confidential
Communications. You have the right to request that
we send communications that contain your health information by alternative
means or to alternative locations. We must accommodate your request if it is
reasonable and you clearly state that the disclosure of all or part of that
information could endanger you.
Right to Inspect and Copy. You
have the right to inspect and copy health information that we maintain about
you in a designated record set. A "designated record set" is a group
of records that we maintain such as enrollment, payment, and claims
adjudication record systems. If copies are requested or you agree to a summary
or explanation of such information, we may charge a reasonable, cost-based fee
for the costs of copying, including labor and supply cost of copying; postage;
and preparation cost of an explanation or summary, if such is requested. We may
deny your request to inspect and copy in certain circumstances as defined by
law. If you are denied access to your health information, you may request that
the denial be reviewed.
Right to Amend. You
have the right to have us amend your health information for as long as we
maintain such information. Your written request must include the reason or
reasons that support your request. We may deny your request for an amendment if
we determine that the record that is the subject of the request was not created
by us, is not available for inspection as specified by law, or is accurate and
Right to Receive an Accounting of
Disclosures. You have the right to receive an
accounting of disclosures of your health information made by us in the six
years prior to the date the accounting is requested (or shorter period as
requested). This does not include disclosures made to carry out treatment,
payment and health care operations; disclosures made to you; communications
with family and friends; for national security or intelligence purposes; to
correctional institutions or law enforcement officials; or disclosures made
prior to the HIPAA compliance date of April
14, 2003. Your first request for accounting in any 12-month period
shall be provided without charge. A reasonable, cost-based fee shall be imposed
for each subsequent request for accounting within the same 12-month period.
Right to Obtain a Paper Copy. You
have the right to obtain a paper copy of this Notice of Privacy Practices at
How to File a Complaint if You
Believe Your Privacy Rights Have Been Violated
If you believe that your privacy rights have been violated,
please submit your complaint in writing to:
Academic Risk Management, Inc.
Attn: Privacy Officer
1005 Glade Road
P.O. Box 1605
Colleyville, TX 76034-1605
You may also file a
complaint with the Secretary of the Department of Health and Human Services.
You will not be retaliated against for filing a complaint.