Notice of Privacy Practices

Last updated [Month DD, YYYY]

This notice is issued by [LEGAL ENTITY NAME, PLLC], doing business as Xenith Health(the “Practice”). It applies to all care we provide, by telehealth and in our Amarillo office, and to every physician, provider, and staff member who works with us.

Your rights

You have the right to:

• Get a copy of your medical record. Ask us how. We will usually provide a copy or summary within 15 business days as Texas law requires, and we may charge a reasonable, cost-based fee.
• Ask us to correct your record if you believe it is incorrect or incomplete. We may say no, but we will tell you why in writing within 60 days.
• Request confidential communications, for example contacting you only at a certain phone number or by email. We will honor reasonable requests.
• Ask us to limit what we use or share. We are not required to agree unless you paid for a service in full out of pocket and ask us not to share that information with your health insurer.
• Get a list of those with whom we have shared your information for the six years before your request, except for treatment, payment, operations, and certain other disclosures.
• Get a paper copy of this notice at any time, even if you agreed to receive it electronically.
• Choose someone to act for you with a medical power of attorney or as a legal guardian.
• File a complaint if you believe your rights have been violated. Contact us at hello@xenithhealth.com or [PHONE], or file with the U.S. Department of Health and Human Services Office for Civil Rights at 200 Independence Avenue S.W., Washington, D.C. 20201, 1-877-696-6775, or www.hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against you for filing a complaint.

Your choices

For the following, tell us what you want us to do and we will follow your instructions:

• Sharing information with your family, close friends, or others involved in your care.
• Sharing information in a disaster relief situation.

If you cannot tell us your preference, for example if you are unconscious, we may share information if we believe it is in your best interest or needed to lessen a serious threat to health or safety.

We never share your information for the following unless you give us written permission:

• Marketing purposes.
• Sale of your information.
• Most sharing of psychotherapy notes.

Our uses and disclosures

We typically use or share your health information in these ways:

• Treat you. We share information with other professionals treating you, including the dispensing pharmacy that fills your prescriptions (King Compounding Pharmacy) and laboratories.
• Run our organization. We use your information to improve care and contact you when necessary.
• Bill for your services. We are a cash-pay practice. We use information to bill you and process payment with our payment processor. We do not bill health insurers.

We are also allowed or required to share information in other ways, usually in ways that contribute to the public good:

• Public health and safety: preventing disease, reporting adverse reactions to medications, reporting suspected abuse or neglect, and preventing a serious threat to anyone’s health or safety.
• Research, under strict conditions.
• Compliance with the law, including inspections by the Texas Medical Board and the U.S. Department of Health and Human Services.
• Organ and tissue donation requests, and work with a medical examiner or funeral director.
• Workers’ compensation, law enforcement, health oversight agencies, and special government functions such as military and national security.
• Lawsuits and legal actions, in response to a court or administrative order, subpoena, or other lawful request.

Electronic disclosure (Texas)

Telehealth

Telehealth visits use video, audio, and secure messaging. We use platforms and vendors that have signed business associate agreements with us. Please join visits from a private location. If you choose to communicate with us by unencrypted email or text message, there is some risk that the message could be read by a third party; you may ask us to use another method at any time.

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 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 here unless you tell us we can in writing. You may change your mind at any time by letting us know in writing.

Changes to 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 on request, in our office, and on this page.

Acknowledgment

You will be asked to acknowledge that you have received this notice when you request a consult and again during intake. Related documents: Telehealth Consent and Website Privacy Policy.

Privacy contact

Privacy Officer, [LEGAL ENTITY NAME, PLLC] d/b/a Xenith Health
[STREET ADDRESS], Amarillo, TX [ZIP]
[PHONE] · hello@xenithhealth.com