DILEK WISE, INC. 1458 Campbell Rd. Ste.250A, Houston TX 77055
a practice of compassion Ph.(713) 294 8090; Fx.(713) 467 6532
www.dilekwise.org
NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
This Notice describes how health information about you may be used & disclosed, and how you can get access to this information. This Notice describes the privacy practices of DILEK WISE, INC., including Dilek Wise, PhD, LMFT, and the interns/therapists under the supervision of Dr.Wise at the office facility specified above. PLEASE REVIEW IT CAREFULLY. The privacy of your health information is important to us.
Patient Health Information
Under federal law, your patient health information is protected and confidential. We are required by law to maintain the privacy of your health information. Patient health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your health information also includes payment, billing, and insurance information.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice avaliable online and upon request. We will provide you with a revised notice in our lobby as well. You may request a personal copy at any time.
Uses & Disclosures of Health Information
We use and disclose health information about you for treatment, to obtain payment, and for healthcare operations, including administrative purposes and evaulation of the quality of care that you receive. Under some circumstances, we may be required to use or disclose the information even without your permission.
Examples of treatment, payment, and healthcare operations
Special uses
We may use your information to contact you with appointment reminders(emails, voicemails, post-cards or letters). We may also contact you to provide information about treatment alternatives or other health-related benefits and services (incl. newsletters, broshures, copy of publications, invoices,balance statements, copy of receipts etc.) that may be of interest to you. We will not use your health information for marketing communications without your written authorization. You may grant or withdraw your authorization to us at any time with a written request.
Other uses and disclosures
We may use or disclose identifiable health information about you for other reasons, even without your consent. Subject to certain requirements, we are permitted to give out health information without your permisson for the following purposes:
Patient Rights
Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information. You may request access by sending us a letter to the address at the end of this Notice. We will prepare a summary of an explanation of your healthinformation for a fee. Contact us using the contact information listed at the end of this Notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to request that we place additional restrictions in which we or our business associates disclosed your health information for purposes, other than treatment, payment, health care operations, and certain other activities, for the last 5 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of yoru health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our egreement (except in emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (you must make your request in writing). Your must specify the alternative means or location, and provide satisfactory explanations how payments will be handled under the alternative means or location request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain wyh the informations should be amended). We may deny your request under certain circumstances.
Electronic Notice: If you receive this notification on our website or by e-mail, you are entitled to receive this Notice in written form.
Questions & Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have vilated your privacy rights, or you disagree with a decision we made about access to yourhealth information or in response to a request you made to amend or restrict the use or disclosure of your halth information or to have us communicate with you by alternative means or alternative locations, you may complain to us at the contact information listed at the end of this Notice. You may also sumbit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. department of Health and Human Services upon request.
We support your right to the privacy of your health information.
We will not retaliate in ay way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact Info:
DILEK WISE, INC.
1458 Campbell Rd. Ste.250A
Houston, TX 77055
Ph: (713) 294 8090
Fx: (713) 467 6532