Foundation Physicians Group

This notice describes how information may be used and disclosed and how you can get access to this information. Please review it carefully.
If you have any questions about this Notice, please contact our Privacy Security Officer at 214-442-8908.

Your Medical Record/ Health Information
Records are kept of your visits with the physician or healthcare providers in this practice. This record contains your health information such as symptoms, diagnoses, exams, procedures, test results, and treatment plan. This health information is called your medical record and serves as a:
• Basis for forming treatment plans
• Means of communication among healthcare professionals who are involved in your care
• Legal document describing care you received
• Means by which you or a third party payer can verify that services billed were actually provided
• Source of information for public health officials

Understanding what is in your medical record and how the information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health record, and make informed decisions regarding disclosure of this information to others.

Your Health Information Rights
Although your medical record is the physical property of the healthcare provider or practice that compiled it, the information belongs to you. You have the rights to:
• Request a restriction on certain uses, restrictions and disclosures of your information
o You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
o If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information
• Obtain a paper copy of the Notice of Privacy Practices upon request
o You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
• Inspect and obtain an electronic or paper copy of your medical record as provided for in 45 CFR 164.524
o You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.
o Ask our staff for the “Request for Access to Patient’s Health Information” form.
o We will provide a copy or a summary of your health information, usually within 15 days of your request. We may charge a reasonable, cost-based fee.
• Amend your health record as provided in 45 CFR 164.528
o You can ask us to correct health information about you that you think is incorrect or incomplete.
o Ask our staff for the “Request for Correction/ Amendment of Health Information” form.
o We may say “no” to your request, but we’ll tell you why in writing within 60 days.
• Obtain and accounting of disclosures of your health information as provided in 45 CFR 164.528
o You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
o We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll

provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Request communication of your health information by alternative means or at alternative locations
o You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
o We will say “yes” to all reasonable requests.
• Revoke your authorization to use or disclose health information expect to the extent that action has already been taken
• Choose someone to act for you
o If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
o We will make sure the person has this authority and can act for you before we take any action.
• File a complaint if you feel your rights are violated
o You can complain if you feel we have violated your rights by contacting us using the information on page 1.
o You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington,
D.C. 20201, calling 1-877-696-6775, or visiting
o We will not retaliate against you for filing a complaint.

Your Choices
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, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation

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.

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

Our Responsibilities
This practice is required to:
• Maintain the privacy and security of your health information
• Let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• Abide by the terms of this notice
• Notify you if we are unable to agree to a requested restriction
• Accommodate reasonable requests you have to communicate health information by alternative means or at alternative locations

• Not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have supplied us. We will not use or disclose your health information without your authorization, except as described in this notice.

Examples of Disclosures for Treatment, Payment, and Health Care Operations Treatment: We can share your health information and share it with professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Health Care Operations- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We can use your health information about you to manage your treatment and services.

Payment- We can use and share your information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

Other Permitted or Required Uses and Disclosures

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

Business Associates: There are some services provided by this practice through contacts with business associates. Examples include physician services in emergency departments, radiology, laboratories, copy services, and billing services. When these services are utilized, we may disclose your health information to our business associates so that they can perform the job we have asked them to do and bill you or your third party payer for services rendered. To protect your health information, we require that our business associates safeguard your information.

Communication with Family: Using their best judgment, the physicians and healthcare providers may disclose to a family member, other relative, or any other person you identify, health information relevant to that person’s involvement in you or payment related to your care.

Research: We may disclose information to researchers when research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, products and product defects.

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 similar programs established by law.

Public Health: As required by law, we may disclose your health information to public health or legal authorities’ charges with preventing or controlling disease, injury, or disability.

Law Enforcement Agencies: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that they have engaged in unlawful conduct or

have otherwise violated professional or clinical standards and are potentially endangering one or more patients, employees, or the public.

Respond to organ and tissue donation requests: We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Comply with the law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to lawsuits and legal actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena.

By signing the Acknowledgement of Receipt of Notice of Privacy Practices, you are agreeing to have your medical records sent via fax or email if so requested by your referring physician.

For More Information
If you have questions and would like additional information, you may contact our Privacy Security Officer at 214-442-8908.