HIPPA Notice of Privacy Practices
Conroe Willis Family Medicine
4015-I45 North, Ste. 220
Conroe, TX 77304
THIS NOTICE DESCRIBES HOW MEDICAL INFORMAITON ABOUT YOU MAY BE USSED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we can use and disclose your protected health information (PHI) to
carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required
by law. It also describes your rights to access and control your protected health information. “Protected Health
Information, PHI” is information about you, including demographic information that may identify you and that
relates to your past, present or future physical or mental health condition and related health care services.
- Uses and Disclosures of Protected Health Information
Your PHI may be used and disclosed by your physician, our office staff and others outside of our
office that are involved in your care and treatment for the purpose of providing health care
services to you, to pay your healthcare bills, to support the operation of the physician’s practice,
and any other use required by law.
Treatment: We will use and disclose your PHI to provider, coordinate, or manage your health care
and any related services. This includes the coordination of management of your healthcare with
a third party. For example, we would disclose your protected health information, as necessary,
to a home health agency that provides care for you. We may also provide your PHI to another
physician that you have been referred to so that the physician has the necessary information to
diagnose and treat you.
Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For
example, obtaining approval for a hospital stay may require that your relevant PHI be sent to your
insurance to obtain approval for the hospital admission.
Healthcare operations: We may use or disclose, as needed, your PHI in order to support the
business activities, employee review activities, training of new medical students, licensing, and
conducting and arranging for business activities. For example, we may disclose your PHI to
medical school students that see patients at our office.
We may use or disclose your PHI in the following situations WITHOUT YOUR AUTHORIZATION.
These situations Include: Public Health issues, as required by law, including communicable
diseases, health oversight, abuse or neglect. Food and Drug Administration Requirements, Legal
proceedings, Law Enforcement, Coroners, Funeral Directors and Organ donation. Research,
Criminal Activity, Military activity, National Security, and Worker’s Compensation.
Required uses and disclosures: Under law, we must make disclosures to you and when required
by the Secretary of the Department of Health and Human Services to investigate or determine
our compliance with the requirements of section 164.500.
Other permitted and Required Uses and Disclosures will be made only with your consent,
authorization or opportunity to object unless required by law.
You may revoke this authorization at any time in writing, except to the extent that your physician
or the physician’s practice has taken an action in reliance on the disclosure indicated in the
authorization. - Your Rights
Following is a statement of your rights with respect to your PHI.
You have the right to request a restriction of your PHI. This means you may ask us not to use or
disclose any part of your PHI for the purpose of treatments, payments, or healthcare operations.
You may also request that any part of your PHI not to be disclosed to family members or friends
who may be involved in your care or for the notification purpose as described in this Notice of
Privacy Practices. Your request must state the specific restriction requested and to whom you
want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If your physician
believes it is in your best interest to permit use and disclosure of your PHI, it will not be restricted.
You then have the right to use another healthcare professional.
You may have the right to request the reception of confidential communications from us by the alternative means
or an alternative location. You also have the right to obtain a paper copy of this notice.
You may have the right to have your physician amend your PHI. If we deny your request for
amendment, you have the right to file a statement of disagreement with us and we may prepare
a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your
PHI.
We reserve the right to change the terms of this notice and will inform you by mail of any changes.
You then have the right to object or withdraw as provided in this notice. - Complaints
You may complin to us or to the Secretary of Health and Human Services if you believe your
privacy rights have been violated by us. You may file a complaint with us by notifying our HIPPA
Compliance Officer of your complaint. We will not retaliate against you for filing a complaint. We
will not retaliate against you for filing a complaint.
We are required by law to maintain the privacy of and provide individuals with this notice of our
legal duties and privacy practices with respect to PHI. If you have any objections to his form,
please ask to speak to our HIPPA compliance office in person or by phone via our main office
number.
Updated: January 13th 2023
