929 College Avenue
Fort Worth, TX 76104
817-336-3431
Private Practice of Medicine and Geriatrics
Robert H. Kelly, MD

Privacy and HIPAA (Health Insurance Portability and Accountability Act)

Due to the HIPAA Act protecting patient privacy, consent will need to be given for certain aspects concerning your care. We will ask you to list acquaintances or family members whom you approve to acquire your personal health information concerning treatment, payment or health care operations for you through our office.  Estella Hernandez is the HIPAA officer for our office.

Dr. Kelly’s brief explanation of HIPAA

February 24, 2003
Dear Patient:
The Federal Government has enacted a complex and confusing law called the Health Insurance Portability and Accountability Act (HIPAA). I want to advise you of certain issues:

  1. Information about your health will be disclosed to your insurer, such as your diagnosis, time of visit, and the charge which is being submitted.

  2. If a consultant is asked to participate in your care, information about your condition will be given to that consulting physician.

  3. At times a less formal consultation will be sought and personal health information may be disclosed.  For example, for a patient with an infection I may ask a medical colleague about the best possible treatment for this patient.

  4. You may restrict release of information in any fashion you desire. You simply have to let me know and appropriate steps will be taken to meet your needs.

Personal health information is available to patients and may be examined or copied at their request.

There are routine copy charges.

We will keep track of disclosures of information to others except in the areas of consultations and billings as mentioned above.

Be assured that your information in this office is kept private.

You can address privacy questions to the office staff.

Complaints may be called to the HIPAA arm of the government, Health & Human Services; Texas Medical Association; or Tarrant County Academy of Medicine (at 817-732-2825). (back to top)

The Federal Government’s Explanation of HIPAA

Permitted Uses and Disclosures of Protected Health Information:
Following are examples of the types of uses and disclosures of your protected health care information that the physician’s office is permitted to make once you have signed a consent form.  Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. These examples are not meant to be exhaustive, but to indicate the types of uses and disclosures that may be made by the office once you have provided consent. (back to top)

Treatment:    We will use and disclose your protected health information to provide, coordinate, or manage your health care and related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to another physician to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information to health care providers (e.g. a specialist, laboratory, nurse, therapist, hospital, administrator, etc.) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment. (back to top)

Payment:    Your protected health information will be used, as needed, to obtain payment for your health care services. Examples include health insurance verification, submission of claims for reimbursement of services provided, pre-certification for services such as a hospital visit, medical necessity review conducted by your insurance company and other utilization review activities. (back to top)

Healthcare Operations:    We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing, and conducting or arranging for other business activities. For example, we may call you by name in the waiting room when your physician is ready to see you. We may use or disclose protected health information, as necessary, to contact you to remind you of your appointment.

We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement with a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. (back to top)

Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization
Other uses and disclosures of your protected health information will be made with your written authorization, unless otherwise permitted or required by law as described below. 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 use or disclosure indicated in the authorization. (back to top)

Others Involved in Your Healthcare:    Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement with your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person who is responsible for your care, of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. (back to top)

Emergencies:   We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physician or another physician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you. (back to top)

Communication Barriers:    We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances. (back to top)

Permitted and Required Uses and Disclosures That May Be Made Without Written Authorization

We may use or disclose your protected health information in the following situations without your consent or authorization.  These situations include:

Required by Law:  We may use or disclose your protected health information to the extent that the use or disclosure is required by law. You will be notified, as required by law, of any such uses or disclosures. (back to top)

Public Health:  We may disclose your protected health information to a public authority that is permitted by law to collect or receive the information.  The disclosure will be made for the purpose of controlling disease, injury, or disability. (back to top)

Communicable Diseases:  We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. (back to top)

Health Oversight:  We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies include government agencies that oversee the healthcare system, government benefit programs, other governmental regulatory programs and civil rights laws. (back to top)

Abuse or Neglect:  We may disclose protected health information to a public health authority that it authorized by law to receive reports of abuse or neglect.  In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. (back to top)

Food and Drug Administration:  We may disclose to the Food and Drug Administration information relative to report adverse events, product defects or problems, track products, to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required. (back to top)

Legal Proceedings:  We may disclose your protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. (back to top)

Law Enforcement:  We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. premises) and it is likely that a crime has occurred. (back to top)

Coroners, Funeral Directors, and Organ Donation:  We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner for medical examiner to perform other duties authorized by law.  We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.  We may disclose such information in reasonable anticipation of death.  Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes. (back to top)

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

Criminal Activity:  Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. (back to top)

Military Activity and National Security:  When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel  1) for activities deemed necessary by appropriate military command authorities,  2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or  3) to foreign military authority if you are a member or threaten foreign military services.  We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. (back to top)

Workers’ Compensation:  Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs. (back to top)

Inmates:  We may use or disclose your protected health information if you are an inmate of a correctional institution and your physician created or received your protected health information in the course of providing care to you.  Disclosures for these purposes would be necessary  1) for the institution to provide health care services to you,  2) for the safety and security of the institution and/or  3) to protect your health and safety or the health and safety of other individuals. (back to top)

Required Uses and Disclosures:  Under the 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 et. seq. (back to top)

Individual Rights

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to request a restriction of your protected health information.  This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes 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.  However, your physician is not required to agree to a restriction that you may request.  With this in mind, please discuss any restriction you wish to request with your physician.  You may request a restriction by completing a Request to Restrict Protected Health Information. (back to top)

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. Please make this request in writing to Dr. Kelly. (back to top)

You may have the right to have your physician amend your protected health information.  This means you may request an amendment of protected health information about you.  In certain cases, we may deny your request for an amendment.  Your request for an amendment may be denied, in whole or in part, if the information that is subject of the request:  1) is not created by the physician,  2) is not part of the designated record set,  3) is not available for inspection because of appropriate denial to access  information (discussed above under Right to Inspect and Copy), or  4) is accurate and complete.  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.  Please contact Dr. Kelly to determine if you have questions about amending your medical record. (back to top)

You have the right to inspect and copy your protected health information.  You must submit your request in writing in order to inspect and/or obtain a copy of your protected health information.  A fee will be charged for the costs of copying, mailing, labor and supplies associated with your request.
Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.  Requests to inspect and/or copy may be denied in certain, limited circumstances; however, a decision to deny access may be reviewable.  In some circumstances, you may have a right to have this decision reviewed by another licensed healthcare professional of our choosing.  Please contact Dr. Kelly if you have questions about access to your medical record. (back to top)

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.  This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes.  You have the right to receive specific information regarding these disclosures that occur after April 14, 2003.  You may request a shorter timeframe.  The right to receive this information is subject to certain exceptions, restrictions and limitations. (back to top)

Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe we have violated your privacy rights.  You may file a complaint by notifying our Privacy Contact of your complaint.  We will not retaliate against you for filing a complaint.

You may contact Dr. Kelly’s office at 817-336-3431 for further information about the complaint process. (back to top)

Changes to Privacy Notic
We reserve the right to change our privacy practices and to apply revised practices to health information we have about you.  Changes will be described in a revised notice that is available to you in our office or upon request. (back to top)