NOTICE OF PRIVACY POLICY
Your Information.
Your Rights.
Our Responsibilities.
This notice describes how your health information may be used and disclosed by us and how you can get access to this information.
PLEASE REVIEW IT CAREFULLY.
To express a HIPAA concern, please:
Email: wecare@mychn.org
Telephone: 281-824-1480
2552 East Broadway St. Suite 102 Pearland, TX 77581| www.mychn.org
YOUR RIGHTS
When it comes to your health information, you have certain rights. Get an electronic or paper copy of your medical record | • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health information, within 15 days of your request. We may, but are not required to, charge a reasonable cost-based fee. We do not charge fees for copies of medical records when you download your records from our OpenFQ Patient Portal. We do not charge fees for patients that are using HHSC grant programs. |
Ask us to correct your medical record | • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days. |
Request confidential communications | • You can ask us to contact you in a specific way (for example, home or office phone) or to send you a text message. • We will say “yes” to all reasonable requests. |
Ask us to limit what we use or share | • 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. • 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 |
Get a list of those with whom we’ve shared information | • You can ask for a list (an “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 we shared it. • We will include all disclosures except for those about treatment, payment, and health care operations, and certain
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Get a copy of this privacy notice | • You can ask for a paper copy of this privacy notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. |
Choose someone to act for you | •If you have given someone your health care power of attorney or if someone is your legal guardian, that person can exercise your privacy rights and make choices about your health information. • We will make sure the person has this authority and can act for you before we take any action or follow his/her directions regarding your health information. |
File a complaint if you feel your rights are violated | • You can file a complaint if you feel we have violated your privacy rights by contacting us: by mail at Compliance Department, Pearland Family Health Center, 2552 East Broadway St. Suite 102 Pearland, TX 77581, or by email at wecare@sfachn.org, or by telephone at 281-824-1480. • 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 www.hhs.gov/ocr/privacy/hipaa/complaints/. • 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 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 • Contact you for fundraising efforts, and when you no longer desire to receive fundraising information, you can tell us not to contact you again. 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 share your information only with your written permission: | • Marketing purposes, unless the marketing is limited to face-to-face marketing • Most sharing of psychotherapy notes. |
OTHER USES AND DISCLOSURES
How do we typically use or share your health information?
We typically use or share your health information in the following ways. Treat you | We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. |
Run our organization | We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. |
Bill for your services | We can use and share your health 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. |
How else can we use or share your health information?
NOTICE OF PRIVACY PRACTICES
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. For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues | We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety |
Do research | We can use or share your health information for research. |
Comply with the law | We will share information about you if state or federal laws require it, including with the Health and Human Service Commission or the Department of Health and Human Services if it wants to see that we’re complying with the federal privacy law(s). |
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 die. |
Work with a medical examiner or funeral director | We can use or share information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services |
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. |
OUR RESPONSIBILITIES
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your protected health information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described in this notice 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.
For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticeapp.html
Change to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.
Effective Date: 1/01/2021
wecare@mychn.org
STATEMENT OF CLIENT
RIGHTS:
1. To receive services without regard to age, sex, color, race, ethnicity, religion, national origin, sexual orientation, gender identity, political affiliation, or disability.
2. To receive services that are considerate, respectful, and culturally sensitive.
3. To privacy: No health information will be disclosed without my informed, written consent unless required by local, state, and federal law.
4. To communicate about services in a language and format that is clear to me.
5. To be informed of all agency rules and regulations related to the provision of services.
6. To initiate a complaint about services and to be fully informed of the agency’s grievance procedure.
7. To withdraw consent for services and/or seek services at another agency without pressure or intimidation.
8. To know the qualifications of all staff providing services to me.
RESPONSIBILITIES:
1. To participate in the development and implementation of service/treatment plans to the extent that I am able.
2. To inform agency staff when I do not understand instructions or information.
3. To keep scheduled appointments, confirming two days in advance; be in the clinic 30 minutes prior to my appointment and to notify agency staff when I need to cancel or reschedule.
4. To follow through with agreed upon activities and to notify agency staff when I am unable to do so.
5. To notify agency staff of services that I have obtained independently.
6. To keep agency staff informed about the quality, appropriateness and timelines of services that I am receiving.
7. To communicate my needs to agency staff as quickly as possible, understanding that they may not be able to satisfy all requests.
8. To conduct myself appropriately when interacting with persons involved in providing services. (Inappropriate behavior includes, but it is not limited to, intoxication, threats, harassment and physical or verbal abuse).
9. To notify the agency of any changes in my personal information including, but not limited to, name, address, home phone, cell phone, and insurance information.
10. To understand that clients, family members of clients, and/or visitors are not permitted to take photographs of or audio/video record CHN workforce members without the express permission of your CHN provider or clinic site director obtained in advance of the photograph or audio/video recording. A violation of this recording limitation may result in a request that you destroy the photo or audio/video recording, including any postings of the materials that have been shared.
FEEDBACK/CONCERN/COMPLAINT
Your feedback is important to us. If you have feedback, a concern or a complaint, we want to hear it. Your information provides us with the ability to improve our performance and processes.
Option 1: Direct Communication. If possible, first address your feedback/ concern/complaint to:
(a) The person perceived as the source of the confusion or conflict. If not resolved or you do not wish to address the other person involved, consult with;
(b) The Department Supervisor or;
(c) The Clinic’s Site Director.
Option 2: File information directly with the Compliance Department.
You may file your feedback, concern or complaint with the Compliance Department by:
(a) Form: requesting a complaint form at any front desk. Complete the form and return it to the front desk;
(b) Email: sending an email to wecare@sfachn.org;
(c) Telephone: contacting the Compliance Department at (281) 824-1480; or
(d) Letter: sending a letter to: Compliance at 2552 East Broadway St. Suite 102 Pearland, TX 77581.
Once your feedback, concern or complaint is received, a Compliance Department employee will contact you within 24 hours and will attempt to reach a resolution within 7 business days.
Should you feel your feedback, concern or complaint cannot be properly handled by Community Health Network, you may contact the appropriate organization as listed below: CDC CDC Project Officer 713-794-9079 Egd8@cdc.gov Department of State Health Services Attention: Investigations Department 1100 W. 49th Austin, Texas 78756 1-800-832-9623 | Texas State Board of Dental Examiners 333 Guadalupe Street Austin, Texas 788701 1-800-821-3205 | Claims for discrimination can be filed with: Health & Human Services Commission Civil Rights Office 701 W. 51st Street, MC W206 Austin, Texas 78751 Phone: 1-888-388-6332 or (512) 438-4313 Fax: (512) 438-5885 A case decision can be appealed by contacting: HHSC Office of Ombudsman 1-877-787-8999 |
PATIENT-CENTERED MEDICAL HOME
What does it mean that Community Health Network (CHN) will soon be a Patient-Centered Medical Home (PCMH)? • We are available when you need us with same-day appointments and our after hours on-call service. • We ask about your personal or family situation and suggest treatment options based on your lifestyle goals. • Our team answers your questions and helps you better understand your health care needs. • We provide equal access to health care regardless of your ability to pay. • We help find potential sources of insurance coverage. • When services are required at other facilities, CHN will assist in coordinating that care. • We work with you based on recognized standards (evidence-based guidelines) to provide you with a high level of care and the ability to support your unique health care needs. | What can I do to get the most out of my visit? • Make a list of your questions. • Write down the names and phone numbers of other health care providers you have visited, including emergency rooms or hospitals. • Make a list of all medications you take (over-the-counter drugs, herbal supplements, vitamins). • Bring your insurance or eligibility information. • Provide any other health care providers with information about your CHN provider. • Contact CHN at least 24 hours prior to your scheduled appointment in the event you need to cancel. For assistance in obtaining medical records or transferring medical records: telephone 281-824-1480 or Email: wecare@mychn.org Visit the CHN’s Patient Portal at: https://portal.mychn.org/ For questions or to make an appointment during or after hours call 281-824-1480. |
CHN PATIENT AGREEMENT
As a member of the CHN Medical Home Team, I, the patient or guardian, will:
- • Let my CHN team know at least 24 hours in advance when I am unable to keep a scheduled appointment.
- • Let my CHN team know when I have moved or changed phone numbers, so my contact information is correct.
- • Call the pharmacy for medication refills at least three (3) business days before running out.
- • Treat CHN team members with respect as we partner together for care. Provide my CHN team feedback so services can improve.
- • Take medications as prescribed and follow the treatment plan; if I cannot do this, I will let my CHN team know.
- • Inform the CHN team when I see providers outside of CHN and tell my team what medications were
- • prescribed or changed, what tests or treatments were done, and any other services performed related to my health.
- • Understand my health risks and conditions; ask questions and learn ways to improve my health and prevent illnesses.
- • Provide my CHN team any information regarding: health condition(s), medical history, illnesses, medications (including over the counter/herbal or supplements), visits with specialists, recent test results, ER visits, and hospital stays.
The CHN team will continue, for you as a patient or guardian, to:
- • Respect you as an individual — we will not make judgments based on age, sex, color, race, ethnicity, religion, national origin, sexual orientation, gender identity, political affiliation, or disability.
- • Respect your privacy — medical information will not be shared with anyone unless you give us permission, or it is required by law.
- • Provide evidence-based care by a team of people (nurses, social workers, medical assistants, nutritionists and support staff) led by your responsible provider who will watch over all your care.
- • Give care that meets your needs and fits with your goals and values.
- • Answer your calls and questions as soon as possible, even after normal business hours; 24 hours a day, 7 days a week.
- • Remind me when it is time to have any check-ups or tests. Help me stay healthy by teaching me to make better choices.
- • Improve my care by using technology—like Electronic Health Records and always strive to improve CHN’s services.
- • Help me get the care needed, even if it is outside of my CHN team.