The Practice uses PHI to provide treatment and other services to you – for example, to diagnose and treat your injury or illness. With your consent, the Practice may disclose information about you to other health care providers who are involved in your care and treatment which may include sharing certain information with specialists, pharmacies and labs.

The Practice may use and disclose your PHI in order to work with the sponsor organization to confirm your eligibility to participate in the Practice and to collect payment. With your consent, the Practice also may disclose PHI to other health care providers so that they may seek payment for services they rendered to you. Our practice will use and with your consent, disclose share your PHI so we can keep taking care of you.

The Practice may use and disclose your PHI in order to work with the sponsor organization to confirm your eligibility to participate in the Practice and to collect payment. With your consent, the Practice also may disclose PHI to other health care providers so that they may seek payment for services they rendered to you. Our practice will use and with your consent, disclose share your PHI so we can keep taking care of you.

The Practice may use your PHI to communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings. The Practice also may use your PHI to identify health-related services and products provided by the Practice that may be beneficial to your health and then contact you about the services and products. The Practice will not use or disclose your PHI for purposes of marketing (as defined by federal privacy laws) without first obtaining your prior authorization.

We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your PHI to your spouse when you bring your spouse with you into the exam room or the hospital during treatment or while treatment is discussed. In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. For example, we may inform the person who accompanied you to the emergency room that you suffered a heart attack and provide updates on your progress and prognosis. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies, or X-rays.

You have the right to request that the Practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. You do not need to give a reason for your request.

If you do not want us to share your PHI, you have the right to request that we not share your PHI for treatment, payment or healthcare operations. This is called requesting restrictions. Additionally, you have the right to request that we share your PHI with only certain individuals involved in your care or the payment for your care, such as family members and friends. We will grant your request as best we can, but may not be able to comply with your request if otherwise required by law, or when the information is necessary to treat you. In order for us to best help you with restrictions, please tell us the following: the information you wish restricted (not shared); whether you are requesting to limit our Practice’s use, disclosure or both; and to whom you want the limits to apply.

You have the right to look at and get a copy of the PHI that is in your designated record set. If you would like to get a copy of your information, you must make your request in writing. To the extent that electronic health records are available, you have a right to an electronic copy of your record, and, if you choose, you may direct us to transmit a copy of the electronic health record to a designated individual or entity. We may charge a fee for copies of your records. Please contact the Practice’s Privacy Officer for information about fees and to request a copy of your records. You have a right to request that we amend your PHI if you feel that the information we have is inaccurate or incomplete, as long as the Practice created the information you wish to amend. We will not make changes to medical information created by another health care provider or changes that would make your medical record inaccurate or incomplete. To request an amendment, contact the Practice’s Privacy Officer, who will assist you in completing the appropriate form.

You have the right to revoke your authorization (or consent) to our use/disclosure of your PHI, as long as you make your request in writing to the Practice. You can revoke your authorization (or consent) for future disclosures, but not for any disclosures made prior to when you first gave your authorization.

You have the right to revoke your authorization (or consent) to our use/disclosure of your PHI, as long as you make your request in writing to the Practice. You can revoke your authorization (or consent) for future disclosures, but not for any disclosures made prior to when you first gave your authorization.

You are entitled to receive a paper copy of our Notice of Privacy Practices at any time. Request a copy at the Practice or by emailing us at [email protected].

You have a right to receive a list of how and to whom certain of your medical information has been disclosed, called an “accounting of disclosures.” The accounting does not include disclosures of your PHI that pertain to treatment, payment or health care operations. To the extent that we use or maintain your PHI in an electronic designated record set, you also have a right to receive an access report indicating who has accessed such PHI (including access for the purposes of treatment, payment, and health care operations) during a period of time up to three years prior to the date of your request. We will provide an access report relating to such disclosures made by us and all of our Business Associates. Requests for an accounting and requests for an access report must be submitted in writing to the Practice.

You have a right to receive a breach notification that complies with applicable Federal and State laws and regulations in the event of a breach of your unsecured PHI.

The Practice is required by law to make sure that the privacy of your PHI is maintained, to provide you with this Notice of our legal duties and privacy practices and to abide by the terms of the Notice that is currently in effect. The Practice reserves the right to change its privacy policies and practices, including this Notice, and to make the new policies and practices, including the revised Notice provisions, effective for all PHI that we maintain. We will post a copy of the current Notice in our office. You may request a copy of it at any time.

The Practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. We also will not use or disclose your health information for the following purposes without your specific, written Authorization:

• For our marketing purposes (although this does not include face-to-face communication about products or services that may be of benefit to you and about prescriptions you have already been prescribed).
  Disclosure of your psychotherapy notes. These are the notes that your behavioral health provider maintains that record your appointments with your provider and are not stored with your medical record.
  Highly Confidential Information. In some instances, we may need specific, written authorization from you in order to disclose certain types of specially-protected information such as psychotherapy notes, HIV status, substance abuse treatment, mental health records, venereal disease information, research involving controlled substances, abortion consent forms, family planning services, and genetic testing information for purposes such as treatment, payment and healthcare operations (“Highly Confidential Information”).
• If you are an emancipated minor, certain information relating to your diagnosis or treatment may be considered Highly Confidential Information and will not be disclosed to your parent or guardian without your consent. Your consent is not required, however, if a physician reasonably believes your condition to be so serious that your life or limb is endangered. Under such circumstances, we may notify your parents or legal guardian of the condition, and will inform you of any such notification. Please note that if you are a parent or legal guardian of an emancipated minor, certain portions of the emancipated minor’s medical record (or, in certain instances, the entire medical record) may not be accessible to you.

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, let the Practice know, and we will follow your instructions.

1. 1. You have both the right and choice to tell us how to:
      • Share information with your family, close friends, or others involved in your care
      • Share information in a disaster relief situation
      • Include your information in a hospital directory
      • Contact you for fundraising efforts

   Note: If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

   1. 1. In these cases we never share your information unless you give us written permission:
         • Marketing purposes
         • Sale of your information
         • Most sharing of psychotherapy notes
      2. In the case of fundraising:
      3. We may contact you for fundraising efforts, but you can tell us not to contact you again.

If you believe your privacy rights have been violated, you may file a complaint with our Practice or with the Secretary of the Department of Health and Human Services (“HHS”). All complaints must be submitted in writing. You will not be penalized for filing a complaint. To file a complaint with the Practice, contact the Privacy Officer. To file a complaint with HHS, contact:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201

Dr. Geetiner Goyal
First Primary Care
8582 Katy Fwy, Suite 110
Houston, TX  77024
(713) 280-7991
[email protected]