THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GETACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The terms "UT Southwestern," "we" and "our" refer to both UT Southwestern Medical Center at Dallas and UT Southwestern Health Systems, a related company that provides services to UT Southwestern Medical Center. If you have any questions about this notice, please call the UT Southwestern privacy officer at 2146486080. UT Southwestern is required by law to provide you with this notice and to abide by the terms of its current notice. April 14,

WHAT IS THIS NOTICE? This notice tells you:

• How we use and release your health information.
• Your rights concerning your health information.
• Our responsibilities to protect your health information.

TO WHOM DOES THIS NOTICE APPLY?

This notice applies to:

• UT Southwestern's workforce.
• Students and trainees of UT Southwestern.
• All departments and clinics of UT Southwestern.
• Any member of a volunteer group who may help you while you are seeking health care at UT Southwestern.

WHAT ARE OUR RESPONSIBILITIES TO YOU?

Your health information is personal. We are required by law to protect the privacy of your health information and will only release your health information as allowed by law or with special written permission (authorization) from you. We use the least amount of health information needed to do our work. Only those who need your health information to provide services are allowed to use it. UT Southwestern protects your information whether verbal, on paper or electronic.

WHEN IS THE NOTICE EFFECTIVE?

This notice is effective on April 14, 2003. UT Southwestern reserves the right to change this notice after the effective date. We reserve the right to make the revised notice apply for all health information that we already have about you, as well as any information we receive in the future. The current notice will be available on our Web site at www.utsouthwestern.edu/hipaa, Revised May 26, 2009.

HOW DO WE USE AND RELEASE YOUR HEALTH INFORMATION?

UT Southwestern has to use and release some of your health information to conduct its business. The following section explains some of the ways we are permitted to use and release health information without authorization from you.

USE AND RELEASE OF YOUR HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION:

TREATMENT PURPOSES

While we are providing you with healthcare services, we may need to share your health information with other healthcare providers or other individuals who are involved in your treatment. Examples include: doctors, hospitals, pharmacists, therapists, nurses and labs that are involved in your care.

PAYMENT PURPOSES

UT Southwestern may need to share a limited amount of health information to obtain or provide payment for the healthcare services provided to you. Examples include:

• Eligibility - UT Southwestern may contact the company or government program that will be paying for your health care. This helps us determine if you are eligible for benefits, and if you are responsible for paying a copayment or deductible.
• Claims - UT Southwestern and businesses we work with share health information for billing and payment purposes. For example, your doctor must submit a claim form to get paid, and the claim form must contain certain health information.

HEALTHCARE OPERATIONS PURPOSES

UT Southwestern may need to share your health information in the course of con-ducting healthcare business activities that are related to providing health care to you. Examples include:

• Quality Improvement Activities - UT Southwestern may use and release health information to improve the quality or the cost of care. This may include reviewing the treatment and services provided to you. This information may be shared with those who pay for your care, or with other agencies that review this data.
• Health Promotion and Disease Prevention - We may use your health information to tell you about disease prevention and healthcare options. For instance, we may send you healthcare information on issues such as women's health, cancer or asthma.
• Case Management and Referral - If you have a health problem or a healthcare need is identified by you or one of your providers, you may be referred to an organization such as a home health agency, medicalequipment company or other community or government program. This may require the release of your health information to these agencies.
• FundRaising Purposes - We may contact you to support UT Southwestern in its mission to provide quality health care, research and education. If you do not want UT Southwestern to contact you for fundraising efforts, please notify the clinic manager or privacy officer.
• Appointment Reminders - UT Southwestern may use your health records to remind you of recommended services, treatments or scheduled appointments.
• Business Associates - There are some services provided at UT Southwestern through contracts with business associates such as medical transcription services and record storage. We require business associates to protect your health information.
• Audits - UT Southwestern may use or release your health information to make sure that its business practices comply with the law and UT Southwestern's policies. Examples include audits involving quality of care, medical bills or patient confidentiality.
• Students and Trainees - Students and other trainees may access your health information as part of their training and educational activities at UT Southwestern.
• Business Activities - We may use or release your health information to perform internal business activities. Examples include: business planning, computersystems maintenance, legal services and customer service.

OTHER PURPOSES

• Required By Law - Sometimes we must report some of your health information to legal officials or authorities, such as law enforcement officials, court officials, governmental agencies or attorneys. Examples include: reporting suspected abuse or neglect, reporting domestic violence or certain physical injuries, or responding to a court order, subpoena, warrant or lawsuit request.
• PublicHealth Activities - We may be required to report your health information to authorities to help prevent or control disease, injury or disability. Examples include: reporting certain diseases, injuries, birth or death information; information of concern to the Food and Drug Administration; or information related to child abuse or neglect. We may also have to report to your employer certain workrelated illnesses and injuries so that your workplace can be monitored for safety.
• Health Oversight Agencies - We may be required to release health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the healthcare system, or for governmental benefit programs.
• Activities Related to Death - We may be required to release health information to coroners, medical examiners and funeral directors so they can carry out their duties related to your death. Examples include: identifying the body, determining the cause of death, or, in the case of funeral directors, carrying out funeral preparation activities.
• Organ, Eye or Tissue Donation - In the event of your death, we may release your health information to organizations involved with obtaining, storing or transplanting organs, eyes or tissue to determine your donor status.
• Research Purposes - At times, we may use or release health information about you for research purposes; however, all research projects require a special approval process before they begin. This process may include asking for your authorization. In some instances, your health information may be used but your identity is protected.
• To Avoid a Serious Threat to Health or Safety - As required by law and stan-dards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and approaching threat to anyone's health or safety.
• Military, National Security or Incarceration/Law Enforcement Custody - We may be required to release your health information to the proper authorities so they may carry out their duties under the law. This may be the case if you are in the military or involved in national security or intelligence activities, or if you are in the custody of law-enforcement officials.
• Worker's Compensation - We may be required to release your health information to the appropriate persons to comply with the laws related to workers' compensation or other similar programs that provide benefits for workrelated injuries or illness.

USE AND RELEASE OF YOUR HEALTH INFORMATION REQUIRING YOUR AUTHORIZATION

• Persons Involved in Your Care - In certain situations, we may share your health information about you to persons involved with your care, such as friends or family members. We may also give information to someone who helps pay for your care. You have the right to approve such releases, unless you are unable to function, or if there is an emergency.
• Notification / Diaster Relief Purposes - In certain situations, we may share your health information with the American Red Cross or another similar federal, state or local disaster relief agency, to help the agency to locate perosns affected by the disaster.
• Directory Information - Except for emergency situations or when you object, the hospitals may share your location and general condition with persons who request information about you by name, and may share all of your directory information with members of the clergy.

WHEN IS YOUR AUTHORIZATION REQUIRED?

Except for the types of situations listed above, we must obtain your authorization for any other types of releases of your health information. If you provide us authorization to use or release health information about you, you may cancel that authorization in writing at any time. Any authorization you sign may be cancelled by following the instructions described on the authorization form. You may receive more information about this by contacting the privacy officer.

WHAT ARE YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION?

UT Southwestern wants you to know your rights regarding your health information.

• Right to Receive This Notice of Privacy Practices - You have the right to receive a paper copy of this notice at any time. You may obtain a copy of the current notice in all clinical areas or by visiting our Web site at www.utsouthwestern.edu/hipaa.
• Right to Request Confidential Communications - You have the right to ask that UT Southwestern communicate your health information to you in different ways or places. For example, you can ask that we only contact you by telephone at work, or that we only contact you by mail at home. We will do this whenever it is reasonably possible. You can find out how to make such a request by contacting the clinic manager or the privacy officer.
• Right to Request Restrictions - You have the right to request restrictions or limi-tations on how your health information is used or released. We have the right to deny your request. You may obtain information on how to ask for a restriction on the use or release of your information by contacting the clinic manager or the privacy officer.
• Right to Access - With a few exceptions, you have the right to review and receive a copy of your health information. Some of the exceptions include:
  • Psychotherapy notes;
  • Information gathered for court proceedings; and
  • Any information your provider feels would cause you to commit serious harm to yourself or to others
  You can get a copy of your health information by submitting a request in writing to the Medical Record Release of Information Office. This office will provide you with the necessary forms and assistance. We may charge you a fee to copy and/or mail your health record to you. If you are denied access to your health record for any reason, UT Southwestern will tell you the reasons in writing. We will also give you information about how you can file an appeal if you are not satisfied with our decision.
• Right to Amend - You have the right to ask that UT Southwestern's information in your health record be changed if it is not correct or complete. You must provide the reason why you are asking for a change. You may request a change by sending a request in writing to the Medical Record Release of Information Office. This office will provide you with the necessary forms and assistance. We may deny your request if:
  • We did not create the information;
  • We do not keep the information;
  • You are not allowed to see and copy the information; or
  • The information is already correct and complete.
  For release of information, please use the following phone numbers: For your University Hospital St. Paul record, call 2146453546. For your University Hospital Zale Lipshy record, call 2146455402. For your University clinic record, call 2146453030.
• Right to a Record of Releases - You have the right to ask for a list of releases of your health information by sending a request in writing to the privacy officer at the address at the end of this notice. Your request may not include dates earlier than the six years prior to the date of your request. If you request a record of releases more than once per year, UT Southwestern may charge a fee for providing the list. The list will contain only information that is required by law. This list will not include releases for treatment, payment, healthcare operations or releases that you have authorized.

WHAT CAN YOU DO IF YOU HAVE A COMPLAINT ABOUT HOW YOUR HEALTH INFORMATION IS HANDLED?

If you believe that your privacy rights have been violated, you may file a complaint with UT Southwestern or with the Secretary of Health and Human Services. To receive help in filing a complaint with UT Southwestern, you may contact our privacy officer at the address at the end of this notice. You will not be denied treatment or penalized in any way if you file a complaint.

www.utsouthwestern.edu

PRIVACY OFFICER CONTACT INFORMATION 

Attn: UT Southwestern Medical Center
c/o Privacy Officer
5323 Harry Hines Blvd.
Dallas, TX 75390-8851