Healthcare providers are required by federal and state laws to maintain the privacy of “Protected Health Information” (PHI) and to provide you with notice about your rights and our legal duties and privacy practices with respect to your PHI. We must abide by the terms of this Notice while it is in effect. Some of the uses and disclosures described in this Notice may be limited in certain causes by applicable state laws that may be more stringent than the federal standards. This Notice is effective as of April 14, 2003. PHI is information about you, including demographic information that can be reasonably used to identify you and that relates to your past, present, or future physical or mental health or condition, the provision of related health care services to you or the payment for that care. This Notice tells you about the ways in which we may collect, use and disclose your PHI to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. Your rights concerning your PHI are also discussed in this Notice. Once you sign Vanguard Inpatient Physician Associates consent/authorization form, we may use and disclose your medical information to treat you, to obtain payment, and to operate the practice. The practice may use or disclose your protected health information only with your written authorization. You may revoke authorization in writing at any time, except to the extent of PHI already disclosed. The practice may use or disclose protected health information about you for other purposes and without your consent if the law requires us to disclose information to government authorities.
You have the following rights regarding your protected health information, and the practice must act on your request within 60 days:
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You may request restrictions on certain uses and disclosures of protected health information, but we are not required to agree to a requested restriction.
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You may request that you receive confidential communication of protected health information.
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You may request to inspect and copy your own projected health information.
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You may request that your information be amended.
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You may request a paper copy of this notice.
The law requires the practice to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices. The law requires the practice to abide by the terms of this notice and to provide individuals with notice revisions. You may complain to the practice or to the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. A complaint can be filed with this practice by writing to: Vanguard Inpatient Physicians 16605 Southwest Freeway, Suite 175, Sugar Land Tx, 77479.
I have read the Notice of Privacy Practices from Vanguard Inpatient Physicians. I understand that my Protected Health Information may be used by Vanguard Inpatient Physicians for the purposes of: Payment, Operations, and Treatment. I also understand that this information may be released to “Business Associates” for the same purposes. I also understand that I have the right to refuse to sign this authorization form. I understand that if I refuse to authorize the release of my health information, Vanguard Inpatient Physicians my not refuse to treat me.
I understand that in order to provide the most effective medical diagnosis and treatment, it may be necessary for my attending physician to discuss my medical condition with certain family members or caregivers. My signature below gives my permission for my physician to discuss my medical condition with the following family members or caregivers if such communication is deemed necessary.