Notice:

Please have your check stubs, social security, insurance card, and immunization cards ready. Failure to disclose insurance and financial information or declination of assistance would mean paying 100% of your bill at CHCL.

Please complete as much information as possible. This will expedite the registration approval process.

CONSENT TO TREATMENT FOR CHCL CLINICS:
I grant the physician(s), employees and such associates, assistants, and other health care providers as my physicians deem necessary attending me/my child the authority to treat and examine my child and/or the examinations, tests, treatments and other services necessary for my care and treatment. I understand that this consent to treatment will be valid and remain in effect as long as I attend the Clinic(s) unless revoked by me in writing.

 

ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITY FOR CHCL CLINICS:
I hereby authorize payment directly to the CHCL Clinic(s) for surgical or medical benefits, including major medical but not to exceed regular charges for those services. I understand that I am financially responsible to the CHCL Clinic(s) for charges incurred.

 

RELEASE FROM LIABILITY:
CHCL Clinic(s) and its agents, representatives, and employees from any and all liability associated with the release of confidential patient information in accordance with this authorization. I understand CHCL Clinic(s) cannot be responsible for use or redisclosure of information by third parties.

 

MEDICARE / MEDICAID ASSIGNMENT FOR CHCL CLINIC(S):
I request that payment of authorized Medicare/Medicaid benefits be made either to me or on my behalf to the CHCL Clinic(s) or other third-party payor for any services furnished me by the CHCL Clinic(s) health care provider. I authorize any holder of medical information about me released to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.

RELEASE OF INFORMATION FOR CHCL CLINIC(S):
CHCL Clinic(s) may disclose all or any part of my medical record to each other and to any person or corporation which is or may be liable under a contract to the clinic or to the patient or to a family member of the patient for all or part of the clinic’s charges.

RELEASE OF DEMOGRAPHIC INFORMATION:
I give consent for CHCL Clinic(s) to share demographic and financial information I give about myself and my family with other health and human service agencies to help me qualify for services. I understand that identifiable information I give will only be shared when I ask another agency/clinic for services.

Welcome to the Community Health Center of Lubbock. Our goal is to provide quality health care to qualified persons in this community, regardless of their ability to pay. If Community Health Center of Lubbock, Inc. is outlining your options, you may be eligible to become our patient. As a patient, your basic rights and responsibilities apply. Community Health Center of Lubbock, Inc. also has rights and responsibilities. We want you to understand these rights and responsibilities so you can help us provide better health care for you. Please read and sign this statement and ask us questions you might have.

Human Rights:
1. You have a right to be treated with respect and dignity regardless of race, religion, sex, national origin, sexual orientation, political affiliation, or ability to pay for services.
Payment for Service:
2. You are responsible for giving us accurate information about your present financial status and any changes in your financial status. We need this information to decide how much to charge you and/or so we can bill private insurance, Medicaid, Medicare, or other benefits for which you may be eligible. If your income is less than the federal poverty guidelines, you will be charged a discounted fee.
3. You have a right to receive explanations of our bill. You must pay, or arrange to pay all agreed fees for medical services with the exceptions of dental services, which are provided on a prepaid basis. If you cannot pay right away, please let us know so we can provide care for you and work out a payment plan.
4. Federal law prohibits us from denying you primary health care services, which are medically necessary, solely because you cannot pay for these services.
Privacy:
5. You have a right to have your interviews, examinations, and treatments in privacy. Your medical records are also private. Only legally authorized persons may see your records unless you request in writing for us to show them to someone else. A complete discussion of your privacy rights is attached as a "Notice of Client Privacy Rights." By signing this document you are indicating that you have received this Notice. The Notice details the various rights granted to you by the Health Insurance Portability and Accountability Act.
Health Care:
6. You are responsible for providing us complete and current information about your health or illness, so that we can give you proper health care. You have a right, and are encouraged, to participate in decisions about your treatment.
7. You have a right to information and explanations in the language you normally speak and in words that you understand. You have a right to information about your health or illness, treatment plan (including risks), and expected outcomes, if known, and information regarding Advance Directives. If you do not wish to receive this information, or if it is medically inadvisable to share this information with you, it will be provided to a legally authorized representative.
8. You are responsible for the appropriate use of our services, which includes following our staff's instructions, making and keeping scheduled appointments, and requesting "walk-in" appointments only when truly necessary. We may not be able to see you unless you have an appointment. If you cannot follow the staff's instructions, please tell us so we can help you.
9. If you are an adult, you have a right to refuse treatment to the extent permitted by law and to be informed of the risks of refusing such care. You are responsible for the outcomes of refusing treatment.
10. You are responsible for the care and treatment that is reasonable for your condition and within our capability. You have a right to be transferred or referred to another facility for services that we cannot provide. But, we do not pay for services that you get somewhere else. Community Health Center of Lubbock, Inc. is not an emergency care facility.
11. If you are in pain, you have a right to receive an appropriate assessment and management, as necessary.
12. You have a right to receive information on how to appropriately use the clinic's services. You are responsible for using the clinic services in an appropriate manner. If you have a question, please ask us.
13. You have a right to receive a copy of our rules about the health services we provide, personal conduct, and the use of our property and resources. You are responsible for obeying these rules. Please observe the "No Smoking, Eating, or Drinking" signs.
14. You are responsible for the supervision of children you bring with you to the clinic. You are responsible for their safety and for the protection of clients and our property.
15. You have a responsibility to keep your scheduled appointments. Missed scheduled appointments cause delay in treating other patients. If you do not keep scheduled appointments you may be asked to meet with the Director or designee to determine the reasons for your missed appointments and whether you can continue as a patient of the Center.
Complaints:
16. If you are not satisfied with our services, please tell us. We want suggestions on how we can improve our services. We will tell you how to file a complaint. If you are still not satisfied with how we handle your complaint, you may complain to the Board of Directors.
17. We will not punish you for filing a complaint and we will continue to provide services.
Termination:
18. If we decide that we must stop treating you as a patient, you have a right to advance notice that explains the reason for the decision and you will be given 30 days to find another health care service. We can decide to stop treating you immediately and without notice if you have threatened the safety of the staff or other clients, failed to pay, or refused to cooperate in your treatment. The Termination of the Patient and Clinic Relationship policy outlines Reasons for which we may stop seeing you as a patient include:

a. Failure to obey clinic rules.
 

b. Intentional failure to report accurate information concerning your health or illness.
 

c. Intentional failure to follow the health care program, such as instructions about taking medications, personal health practices, or follow-up appointments, as recommended by your provider or staff.
 

d. Creating a threat to the safety of the staff and other clients.
 

e. Intentional failure to report accurately your financial status.

19. If we stop seeing you as a patient Notice of Termination of the Patient and Clinic Relationship, you have the right to appeal the decision to a Board of Directors. Unless you're in a medical emergency, we will not continue to see you as a patient while you are appealing the decision.

 

In order to better serve the needs of the community, some health care services are available from the center via telemedicine and telehealth. Telemedicine medical services and telehealth services are healthcare services delivered by physicians and health professionals to patients located at a different physical location using telecommunications or other information technology. Telecommunications or other information technology may also be used for virtual check-ins, e-visits, initial evaluations, screenings, and pre- and post-visit communication by center staff. Providers may include, but are not limited to, Physicians, Advanced Practice Registered Nurses, Physician Assistants, Professional Counselors, Marriage and Family Therapists, Clinical Social Workers, and Psychologists.

Information shared may include patient medical records, medical images, medical audio or video files, two-way audio and video, and output data from medical devices. The systems used by the center to transmit and receive this information will incorporate network and software security protocols intended to protect the confidentiality of the patient's identity and information.

I hereby and voluntarily consent to authorize CHCL's physicians and such associates, technical assistants, or other healthcare providers as they may deem necessary to participate in my/my child's medical care through the use of telemedicine and/or telehealth.

I understand the following:
1. The same standard of care applies to health care services delivered via telemedicine and/or telehealth as applies to an in-person visit.
2. The laws that protect the privacy and confidentiality of health care information apply to telemedicine and/or telehealth services.
3. I will not be physically in the same room as my healthcare provider. I will be notified of and my consent obtained for anyone other than my healthcare provider (medical residents, nursing students, etc.) present in the room.
4. There are certain hazards and risks connected with all forms of treatment, regardless of the medium used, and my consent is given knowing this.
5. In the event the telemedicine and/or telehealth session is interrupted due to service interruptions, interception, and technical difficulties, alternative means of communication may be implemented or an in-person medical evaluation may be necessary.
6. I have the right to refuse to participate or decide to stop participating in a telemedicine and/or telehealth visit at any time. My refusal will be documented in my medical record and my refusal will not affect my right to future care. I may invoke my right at any time by contacting CHCL at 806-765-2611.
7. This visit may need to be converted into an in-person visit for situations and/or cases that require a physical exam in order to determine a diagnosis and for appropriate treatment and care.
8. CHCL and CHCL's healthcare providers have no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission.
9. This document will become a part of my medical record.
10. I may consent to my medical record or a report containing an explanation of treatment provided being sent to my primary care physician.
11. The disclosure of my medical information to CHCL healthcare providers and health professionals, including the audio and/or video, will be by electronic transmissions. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand the electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and electronic tampering.
12. This informed consent for telemedicine and/or telehealth is valid and remains in effect as long as I am a patient of the center, until I withdraw my consent, or until the center changes its service and asks me to complete a new consent form.

By signing this form, I attest that: (1) I have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternative to telemedicine visits shared in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).

NOTICE CONCERNING COMPLAINTS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

Texas Medical Board Attention: Investigations
333 Guadalupe, Tower 3, Suite 610
P.O. Box 2018, MC-263
Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353

For more information, please visit our website at www.tmb.state.tx.us.

In order to give you the best possible care, we need to know about you/or your caregiver and how you/they learn. The following information and questions will help us to help you learn about taking care of yourself. Para darle el cuidado mejor posible, tenemos que saber como usted, o la persona responsable por su cuidado, aprende. La información y las preguntas siguientse nos ayudarán a ayudarle a usted aprender como cuidarse.

The following information pertains to Patient or Caregiver:

Factors which affect learning (Los factores que afectan el aprendizaje):

Please let us know, at any time, if you don’t understand any of the information we are giving you. We want to work with you to make it easy for you to understand

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this Notice, please contact CHCL’s Privacy Officer at: (806) 765-2611 Ext. 1106

WHO WILL FOLLOW THE PRIVACY PRACTICES DESCRIBED IN THIS NOTICE

This Notice of Privacy Practices (Notice) describes the privacy practices of the Community Health Center of Lubbock (CHCL) and its workforce members (including employees, contractors, physicians, nurses, other licensed or certified personnel, volunteers, and front desk, billing and administrative personnel) who have a need to use your health information to perform their jobs. It also applies to any individuals authorized to enter information into your medical record. Your other health care providers may have different policies regarding their use and disclosure of your health information created at their location.

ABOUT YOUR HEALTH INFORMATION

We understand that health information about you and your health is personal, and protecting your health information is important to us. We create a record of the care and services you receive at CHCL. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by CHCL, whether made by CHCL personnel or other health care providers, whether stored and transmitted electronically or by other means. We are required by law to:

• Maintain the privacy of health information that identifies you (with certain exceptions);

• Give you this Notice of our legal duties and privacy practices with respect to health information we collect and maintain about you; and

• Follow the terms of this Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we may use and disclose health information. Following each category is an explanation. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• DISCLOSURE AT YOUR REQUEST. We may disclose health information when requested by you. This disclosure at your request may require a written authorization by you.

• FOR TREATMENT. We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, students, or other CHCL personnel who are involved in taking care of you at CHCL. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.Additionally, the doctor may need to tell the social worker if you have diabetes so we can arrange for appropriate follow-up. Different areas of CHCL may also share health information about you in order to coordinate the different care you need, such as medications, lab work and x-rays. We also may disclose health information about you to people outside CHCL who may be involved in your healthcare after you leave CHCL, such as nurses, social workers, family members, or clergy. We may also use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

• FOR PAYMENT. We may use and disclose health information about you so that the treatment and services you receive at CHCL may be billed to and payment may be collected from you, an insurance company, or a third party such as Workers Compensation. For example, we may need to give your health plan information about a procedure you received at CHCL so your health plan will pay us or reimburse you for the procedure or encounter. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your health plan will cover the treatment.

• FOR HEALTH CARE OPERATIONS. We may use and disclose health information about you for our health care operations activities. These uses and disclosures are necessary to operate CHCL efficiently and make sure that all of our patients receive quality care. For example, we may use health information to review the safety and quality of our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine and analyze health information about many CHCL patients to decide what additional services CHCL should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, students, volunteers, and other Center personnel for review and learning purposes. Additionally, we may combine the health information we have with health information from other centers to compare how we are doing and to see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific patients are.

ADDITIONAL USES AND DISCLOSES OF HEALTH INFORMATION:

• AS REQUIRED BY LAW. We will disclose health information about you when required to do so by federal, state, or local laws or regulations.

• DIRECTORY. We may include certain limited information about you in the CHCL directory while you are a patient at CHCL. This information may include your name, location at our facility, general condition, and religious affiliation to clergy. Unless there is a specific written request from you to the Privacy Officer listed herein to the contrary, this directory information may also be released to people who ask for you by name.

• SIGN-IN SHEET. We may use and disclose health information about you by having you sign in when you arrive at CHCL. We may also call out your name when you are ready to be seen.

• APPOINTMENT AND PATIENT RECALL REMINDERS. We may use and disclose your health information to contact you to remind you regarding appointments or for health care that you are to receive.

• BUSINESS ASSOCIATES. Some of our functions are accomplished through contracted services provided by Business Associates. A business associate may include any individual or entity that receives your health information from us in the course of performing services for CHCL. Such services may include, without limitation, legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.

• DISASTER RELIEF. We may disclose information about you to an entity assisting in disaster relief so that your family can be notified about your condition, status and location.

• FUNDRAISING.We may use information about you in an effort to raise money for CHCL and its operations. We may disclose health information to a foundation related to CHCL so that the foundation may contact you in raising money for CHCL. We only would release contact information, such as your name, address and phone number, and the dates you received treatment or services at CHCL. If you do not want CHCL to contact you for fundraising efforts, you must notify CHCL's Chief Executive Officer (CEO) at: (806) 765-2611 Ext. 1100 or in writing via email at: ceo@chclubbock.org. Additionally, each fundraising communication will include an opt-out opportunity.

• HEALTH-RELATED PRODUCTS AND SERVICES. We may use and disclose health information to tell you about our health-related products or services that may be of interest to you.

• FAMILY, FRIENDS, OR OTHER INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. We may disclose your health information to notify or assist in notifying a family member, your personal representative, or another individual involved in or responsible for your health care about your location at CHCL, your general condition, or in the event of your death. We may also disclose information to someone who helps arrange for payment for your care. If you are able and available to agree or to object, we will give you the opportunity to agree or object prior to making these disclosures, although we may disclose this information in the case of a disaster even over your objection if we believe it is necessary to respond to the disaster or emergency situation. If you are unable or unavailable to agree or object, we will use our best judgment in any communication with your family, personal representative, and other involved individuals.

• RESEARCH. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patients' need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process. However, we may also disclose health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the health information they review does not leave CHCL.

• TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. For example, we may notify emergency response personnel about a possible exposure to Acquired Immune Deficiency Syndrome (AIDS) and/or the Human Immunodeficiency Virus (HIV). Any such disclosure, however, would only be to the extent required or permitted by federal, state or local laws and regulations.

• CHANGE OF OWNERSHIP. In the event that CHCL is sold or merged with another organization, your health information/medical record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another Center, medical group, physician or other healthcare provider.

 

SPECIAL SITUATIONS

• FUNERAL DIRECTORS, CORONERS, AND MEDICAL EXAMINERS. We may disclose your health information to funeral directors as necessary to carry out their duties. We may also disclose health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

• HEALTH OVERSIGHT ACTIVITIES. We may disclose your health information to a health oversight agency for activities authorized by federal, state, or local laws and regulations. These oversight activities include, for example, audits, inspections, licensure reviews, investigations into illegal conduct, and compliance with other laws and regulations. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

• LAW ENFORCEMENT. We may release your health information if asked to do so by a law enforcement official in the following circumstances: (a) in response to a court order, subpoena, warrant, summons, or similar process; (b) to identify or locate a suspect fugitive, material witness, or missing person; (c) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; (d) about a death we believe may be the result of criminal conduct; (e) about criminal conduct at CHCL; or (f) in emergency situations to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.

• LAWSUITS AND DISPUTES. If you are involved in a lawsuit or a dispute, we may disclose your health information to the extent expressly authorized by a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if reasonable efforts have been made to notify you of the request (which may include written notice to you) and you have not objected, or to obtain an order protecting the information requested.

• MILITARY AND VETERANS. If you are a member of the armed forces, we may release health information about you as required by military authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

• NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES. We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

• ORGAN AND TISSUE PROCUREMENT ORGANIZATIONS. If you are an organ donor, we may disclose health information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary, to facilitate organ or tissue donation and transplantation.

• PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS. We may disclose health information about you to authorize federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or to conduct special investigations.

• PUBLIC HEALTH REPORTING. We may disclose health information about you for public health activities. We will only make this disclosure if you agree or when required or authorized by law. These activities generally include the following: (a) to prevent or control disease, injury, or disability; (b) to report births and deaths; (c) to report the abuse or neglect of children, elders, and dependent adults; (d) to report reactions to medications or problems with products; (e) to notify people of recalls of products they may be using; and (f) to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

• VICTIMS OF ABUSE, NEGLECT OR DOMESTIC VIOLENCE. We may disclose your health information to notify the appropriate government authority if we believe that a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure when required or authorized by law.

• WORKERS' COMPENSATION. We may disclose health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

• SECURITY CLEARANCES. We may use medical information about you to make decisions regarding your medical suitability for a security clearance or service abroad. We may also release your medical suitability determination to the officials in the Department of State who need access to that information for these purposes.

• MULTIDISCIPLINARY PERSONNEL TEAMS. We may disclose health information to a state or local government agency or a multidisciplinary personnel team relevant to the prevention, identification, management, or treatment of an abused child and the child's parents, or elder abuse and neglect.

• SPECIAL CATEGORIES OF HEALTH INFORMATION. In some circumstances, your health information may be subject to additional restrictions that may limit or preclude some uses or disclosures described in this Notice or Privacy Practices. For example, there are special restrictions on the use and/or disclosure of certain categories of health information, such as: (a) AIDS treatment information and HIV test results; (b) treatment for mental health conditions and psychotherapy notes; (c) alcohol, drug abuse, and chemical dependency treatment information; and/or (d) genetic information, which are all subject to special restrictions. In addition, government health benefit programs, such as Medicare or Medicaid, may also limit the disclosure of patient information for purposes unrelated to the program.

 

YOUR PRIVACY RIGHTS

You have the following rights regarding health information we maintain about you:

• RIGHT TO INSPECT AND COPY. You have the right to inspect and copy health information that may be used to make decisions about your care. Usually this includes medical and billing records but may not include some mental health information. If you request a copy of your health information that may be used to make decisions about your care, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to:

Community Health Center of Lubbock, Inc.
1610 5th Street
Lubbock, TX 79401

Attention: Privacy Officer

We may deny your request to inspect and copy in specific circumstances. If you are denied access to your health information, you may request that the denial be reviewed. Another licensed health care professional chosen by CHCL will review your request and the denial. The person conducting the review will not be the person who denied your request. CHCL will comply with the outcome of the review.

• RIGHT TO REQUEST RESTRICTIONS. You have the right to request a restriction or limitation on the health information CHCL uses or discloses about you for treatment, payment or health care operations. You can also request a restriction or limitation on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

   

• WE RESERVE THE RIGHT TO ACCEPT OR REJECT YOUR REQUEST. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. We will notify you if we do not agree to a requested restriction. To request restrictions, you must submit a written request to CHCL at the above address. In your request, you must state: (a) what information you want to limit; (b) whether you want to limit its use, disclosure or both; and (c) to whom you want the limits to apply, for example, no disclosures to your spouse.

• RIGHT TO RESTRICT DISCLOSURE FOR SERVICES PAID BY YOU IN FULL. You have the right to restrict the disclosure of your health information to a health plan if the health information pertains to health care services for which you paid in full directly to CHCL and the disclosure is not otherwise required by law.

• RIGHT TO AMEND. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment to your health information for as long as the information is kept by or for CHCL. You must make your request to amend your health information in writing and submit it to CHCL at the above address. You must include a reason that supports your request. In addition, we may deny your request if you ask us to amend information that:

1. Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

2. Is not part of the health information kept by or for CHCL;

3. Is not part or the information which you would be permitted to inspect and copy; or

4. Is accurate and complete.

The law permits us to deny your request for an amendment if it is not in writing or does not include a reason to support the request.
Even if CHCL denies your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your medical record, we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

• REQUEST AN ACCOUNTING OF DISCLOSURES. You have the right to request an "accounting of disclosures." Such an accounting is a list of the disclosures we made of health information about you other than our own uses for treatment, payment and health care operations (as those functions are described above) and with other expectations pursuant to law. To request this list or accounting of disclosures, you must submit your request in writing to CHCL at the above address. Your request must state a time period that may not be longer than six (6) years. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

• RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. You must make your request for confidential communications in writing to CHCL at the address noted above. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

• RIGHT TO OBTAIN A PAPER COPY OF THIS NOTICE. You have the right to receive a paper copy of this Notice. You may request a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.

   

• RIGHT TO NOTICE OF BREACH. You have the right to be notified if we or one of our Business Associates becomes aware of an improper disclosure of your health information.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice at any time. We reserve the right to make the revised or changed Notice effective for all health information we have about you as well as any information we receive in the future. We will post a copy of the current Notice in an obvious place at CHCL. The Notice will contain the effective date on the first page, in the top right-hand corner. If we amend this Notice, we will offer you a copy of the current Notice in effect. You may request a copy of the current Notice each time that you visit CHCL for services or by calling CHCL and requesting that the current Notice be sent to you in the mail.

FOR MORE INFORMATION, TO FILE A COMPLAINT OR TO REPORT A PROBLEM

If you believe that your privacy rights have been violated, please let us know promptly so we can address the situation. You may file a complaint with CHCL and/or with the Secretary of the Federal Department of Health and Human Services. All complaints must be submitted in writing.

To file a complaint with CHCL, send a written complaint to CHCL's Privacy Officer at:

Community Health Center of Lubbock, Inc.
1610 5th Street
Lubbock, TX 79401

Attention: Privacy Officer

If you would like to discuss a problem without submitting a formal complaint, you may contact the Privacy Officer by telephone at (806) 765-2611 Ext. 1106, by facsimile at (806) 765-5826, or via e-mail at: privacyofficer@chclubbock.org. In addition, you may contact the CEO by telephone at (806) 765-2611 Ext 1100, by facsimile at (806) 687-5826, or via e-mail at ceo@chclubbock.org

You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will stop the uses and disclosures allowed by that permission, except to the extent that we have already acted in reliance on your permission. For example, we are unable to take back any disclosures we have already made with your permission.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE

We will ask you to sign an acknowledgment that you received this Notice. By signing this page, you acknowledge that you have received all 5 pages of this document.

 

Press "Continue" to preview your information. Once you have verified everything is correct, please hit "Sign Document" to complete your submission.
Note: Changes cannot be made after selecting "Sign Document."