NEW: COVID-19 testing sites have been added to our calendar.
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This practice uses and discloses healthy information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.
This notice describes our privacy practices. You can request a copy of this notice at any time. For more information about this notice or our privacy practices and policies, please contact our office.
We are permitted to use and disclose your medical information to those involved in your treatment. For example, your care may require the involvement of a specialist. When we refer you to a specialist, we will share some or all of your medical information with that physician to facilitate the delivery of care.
We are permitted to use and disclose your medical information to bill and collect payment for the service provided to you. For example, we may complete a claim form to obtain payment from you insurer or HMO. The form will contain medical information, such as a description of the medical service provided to you, that your insurer or HMO needs to approve payment to us.
Health Care Operations
We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered.
For example, we may ask another physician to review this practice’s charts and medical records to evaluate our performance so that we can ensure that only the best health care is provided by this practice.
Disclosures That Can Be Made Without Your Authorization
There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object. In other situations we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and disclosures. However, any revocation will not apply to disclosures or uses already made or taken in reliance on that authorization.
Public Health, Abuse or Neglect, and Health Oversight
We may disclose your medical information for public health activities. Public health activities are mandated by federal, state, or local government for the collection of information about disease, vital statistics (like births and death), or injury by a public health authority. We may disclose medical information, if authorized by law, to a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may disclose your medical information to report reactions to medications, problems with products, or to notify people of recalls or products they may be using.
We may also disclose medical information to a public agency authorized to receive reports of child abuse or neglect. Texas law requires physicians to report child abuse or neglect. Regulations also permit the disclosure of information to report abuse or neglect of elders or the disabled.
We may disclose your medical information in the course of judicial or administrative proceedings in response to an order of the court ( or the administrative decision-maker) or other appropriate legal process. Certain requirement must be met before the information is disclosed.
If asked by a law enforcement official, we may disclose your medical information under limited circumstances provided that the information:
We may also release information if we believe the disclosure is necessary to prevent or lessen an imminent threat to the health or safety of a person.
We may disclose your medical information as required by the Texas workers’ compensation law.
If you are an inmate or under the custody of law enforcement, we may release your medical information to the correctional institution or law enforcement official. This release is permitted to allow the institution to provide you with medical care, to protect your health or the health and safety of others, or for the safety and security of the institution.
Military, National security and Intelligence Activities, Protection of the President
We may disclose your medical information for specialized governmental functions such as separation or discharge from military service, requests as necessary by appropriate military command officers (if you are in the military), authorized national security and intelligence activities, as well as authorized activities for the provision of protective services for the President of the United Sates, other authorized government officials, or foreign head of state.
Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors
When a research project and its privacy protections have been approved by an institutional Review Board or privacy board, we may release medical information to researchers for research purposes. We may release medical information to organ procurement organizations for the purpose of facilitating organ, eyes, or tissue donation if you are a donor. Also, we may release your medical information to a coroner or medical examiner to identify a deceased or a cause of death. Further, we may release your medical information to a funeral director where such a disclosure is necessary for the director to carry out his duties.
Required by Law
We may release your medical information where the disclosure is required by law.
Your Rights Under Federal Privacy Regulations
The United States Department of Health and Human Services created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act ( HIPAA ). Those regulations create several privileges that patients may exercise. We will not retaliate against a patient that exercises their HIPAA rights.
You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment, or healthcare operations. We do NOT have to agree to this restriction, but if we do agree, we will comply with your request except under emergency circumstances.
To request a restriction, submit the following in writing: (a) The information to be restricted, (b) what kind of restriction you are requesting (i.e. on the use of information, disclosure of information or both), and (c) to whom the limits apply. Please send the request to the address and person listed below.
We can refuse to provide some of the information you ask to inspect or ask to be copied if the information
We can refuse to provide access to or copies of some information for other reasons, provided that we provide a review of our decision on your request. Another licensed health care provider who was not involved in the prior decision to deny access will make any such review.
Texas law requires that we are ready to provide copies or a narrative within 15 days of your request. We will inform you of when the records are ready or if we believe access should be limited. If we deny access, we will inform you in writing.
HIPAA permits us to charge a reasonable cost based fee. The Texas State Board of Medical Examiners ( TSBME ) has set limits on fees for copies of medical records that under some circumstance may be lower than the charges permitted by HIPAA. In any event, the lower of the fee permitted by HIPAA or the fee permitted by the TSBME will be charged.
Amendment of Medical Information
You may request an amendment of your medical information in the designated record set. Any such request must be made in writing to the person listed below. We will respond within 60 days of your request. We may refuse to allow an amendment if the information:
Even if we refuse to allow an amendment, you are permitted to include a patient statement about the information at issue in your medical record. If we refuse to allow an amendment we will inform you in writing. If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we know have the incorrect information.
Accounting of Certain Disclosures
The HIPAA privacy regulations permit you to request, and us to provide, an accounting of disclosures that are other than for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for an accounting to the person listed below. Your first accounting of disclosures ( within a 12 –month period ) will be free. For additional requests within that period we are permitted to charge for the cost of providing the list. If there is a charge we will notify you and you may choose to withdraw or modify your request before any cost are incurred.
Appointment Reminders, Treatment, Alternatives, and Other Health-related Benefits
We may contact you by telephone, mail, or both to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you.
If you are concerned that your privacy right have been violated, you may contact the person listed below. You may also send a written complaint to the United Stated Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United State Department of Health and Human Services is:
U. S. Department of Health and Human Services
7500 Security Blvd , C5-24-04
Baltimore , MD 21244
Our promise to you
We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protected health information, and to abide by the terms of the notice of privacy practices in effect.
Questions and Contact Person for Request
If you have any questions or want to make a request pursuant to the rights described above, please contact:
This is effective on the following date: April 14, 2003
We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen.
Welcome to DJR Medical. For your first appointment we ask that you arrive about 30 minutes early to fill out the necessary paperwork. We will be obtaining your insurance information before your appointment so that it may be verified ahead of time and avoid delay and confusion the day of your visit.
Remember to bring your insurance card and a picture ID as insurance plans require us to obtain this. Please also bring with you any old medical records you have, your vaccination records, and all of your bottles of medications, both prescription and over the counter vitamins and supplements. If you have old medical records to send for, bring the name and address of the medical facility.
You may fill out, print and fax a copy of three forms to our office prior to your appointment time to expedite your check in time or you may fill them out at your appointment time. The forms include: i) Patient Information ii) Health History Questionaire and iii) Insurance Verification.
Patients are expected to pay at the time services are rendered. No refunds will be granted for either services or medications dispensed. Health Department regulations will not allow us to accept any returned bottles once they leave our premises, regardless of their conditions.
When another doctor requests a copy of medical records, they will be mailed to the doctor (with written authorization) at no charge. There is a charge for copies of medical records in all other situations (law firms, insurance companies, etc.). There is also a charge for letters, narratives and special forms to be filled out.
The office is open for appointments and staff is available to answer routine calls from 9:00 AM to 5 PM Monday through Friday, and 9:00 AM to 1:00 PM on Saturday. There is voice mail on which to leave NON EMERGENCY calls at other hours. Our policy is to answer your messages promptly.
If you have an urgent problem, please call us so that we may determine how to best serve you. There are many urgent conditions that are more appropriately handled in a hospital Emergency Room. Occasionally, if I am out of the office or my schedule is full for that day and you have an urgent problem, you may be given the opportunity to see my associate Dr. _______As a courtesy to us and your fellow patients we ask to call 24 hours in advance if you will be unable to keep your appointment.
To receive lab and test results please call the office at least 5 working days after they are completed.
For refills of routine maintenance medications please call your pharmacy and ask them to contact us if refill authorization is needed at least seven (7) days before you run out of your medications. Phone requests for non-maintenance, non-emergency refills should be made during office hours.
Emergencies and Hospitals
For major emergencies you should call 911 or proceed to the closest emergency room.
For minor urgent problems that occur when the office is closed, need to be seen in person by a physician, and cannot wait until the office opens you may go to any urgent care center that accepts your insurance plan.
The hospital to which you would be admitted if such a need were to arise is determined by your insurance plan and by where the physician who is admitting you has staff privileges-this may be me, one of my associates, or a specialist you are seeing.
If your plan is accepted at Hermann Memorial Southwest Hospital or West Houston Medical Center, I recommend you go to either one of these facilities. I will usually be asking the Internal Medicine hospital based specialists ("hospitalists") or my other associates to follow my patients while they are in the hospital. I will be resuming your office based care upon discharge.
We welcome your comments and suggestions. We are accepting new patients and I welcome your kind referrals of friends or family.
Accountable Health Plan of Texas
AETNA US HEALTHCARE-PPO/POS/HMO
Affordable/First Health Network
BCBS of Texas, Inc
Beech Street/CAPP Care
BCE Emergis PPO
CIGNA - HMO/POS
CIGNA - PPO
CIGNA Open Access
Coastal Comp Health Network - PPO/WC
Community Health Choice
Evolutions Healthcare Systems
Freedom of Choice PPO
Galaxy Health Network (Mg'd Care)
Houston Healthcare Purchasing HHPO
Integrated Health Plan
Memorial Hermann Health Network, IPA
Accountable Health Plan
Blue Choice PPO
Community Health Choice
Freedom of Choice PPO
Houston Healthcare Purchasing Organization
MHHNP TPA Acceptance Statement
One Health HMO/POS
One Health PPO
Preferred Health Network (PHN)
Private Healthcare Systems EPO
Private Healthcare Systems PPO
Single Signature Authority
Texas Municipal League
Methodist Hospital Custom Network
Natioanl Healthcare Alliance
National Preferred Provider Network
National Provider Network-PPO
Newton Healthcare Network
One Health Plan Of Texas, Inc. PPO/HMO
Physicians Health Plan
Plan Vista Solutions PPO
Preferred Health Network
Private Health Care System
Provider Select, Inc.
Rockport Healthcare Group, Inc.
Texas Health Network
Texas Municipal League PPO
Texas True Choice
United Payors & United Provider PPO
USA Managed Care Organization PPO
United Health Care - PPO/HMO
St. Luke's IPA
AETNA U.S. Healthcare -HMO/PPO/POS
Amerihealth Insurance Co.-HMO
Amerihealth Insurance Co.-PPO
Beech Street - PPO
BCBS HMO Blue
Brazosport Health Network
Centra Healthcare Administrative Services
Evolutions Healthcare Resources, Inc.
FORMOST - PPO
Galaxy Health Network (Mg'd Care)
Golden Triangle Healthcare Management Corporation
Houston Healthcare Purchasing Organization (HHPO)
Integrated Medical Systems - PPO
John Hancock "Classic" - PPO
MEDCORP Southwest, Inc.
Matagorda Health Insurance Plan - PPO
Medical Community Insurance Company/Gulf Coast IPA - PPO
MEDICUS International, Inc.
Memorial Sisters of Charity Health Plans-HMO-Options POS-
Fully Insured PPO, Self Funded PPO, Choice 65
National Healthcare Alliance, Inc.-PPO/EPO
National Preferred Provider Network
National Provider Network-PPO
NYLCare - PPO
One Helath Plan of Texas, Inc.-PPO
Preferred Health Network - PPO
Private HealthCare Systems(PHCS)
Provider Networks of America (ProNet)
Southwest Preferred Network
Tareco, Inc. - PPO
Teachers Retirement System of Texas - PPO
Texas Municipal League -PPO
Unicare - PPO
United Health Care
USA Managed Care - PPO/Worker's Compensation
USC Health Services - PPO
Insurance plan participation are subject to change without notice.