Joint Notice of Privacy Practices

What is the purpose of this notice?
This notice tells you how Children’s uses and discloses your medical information and your rights regarding your medical information.

• Children’s Medical Center of Dallas and its medical staff,
• The University of Texas Southwestern Medical Center at Dallas, its faculty physicians who practice at Children’s, and its residents and fellows,
• Dallas Physician Medical Services for Children, Inc., Anesthesiologists for Children, and other health care providers under common ownership or control by Children’s Health Services of Texas whose names will be made available to you upon request.

The above list includes workforce members, volunteers and trainees whose conduct is directly
controlled by Children’s. NOTE: The physicians who treat you/your child at Children’s are not
employees or agents of Children’s. They are either (i) independent physicians engaged in the
private practice of medicine who have staff privileges at Children’s; (ii) independent physicians
who are independent contractors and have staff privileges at Children’s; (iii) physicians employed
by The University of Texas Southwestern Medical Center or another institution who have staff
privileges at Children’s; or (iv) physicians participating in the care of patients as part of a postgraduate
medical education program.
For purposes of this notice, each covered entity subject to this notice is referred to as “Children’s”
or “we.” “You” and “your” refer to the person authorized to make health care decisions for the
Children’s patient if the patient lacks that authority.

Who may use and disclose your medical information?
Children’s maintains your child’s medical information in a confidential manner, as required by
law. However, Children’s must share this medical information as necessary to provide you with
quality health care. Children’s, its medical staff, The University of Texas Southwestern Medical
Center at Dallas, and other covered entities participating in their organized health care
arrangement also will share medical information with each other as necessary to carry out
treatment, payment and health care operations relating to the organized health care arrangement.

What are treatment, payment and health care operations?
Treatment includes sharing information among health care providers involved in your child’s
care. For example, your child’s doctor may share information about your child’s condition with
pharmacists to discuss appropriate medications, or with radiologists or other health care providers
in order to make a diagnosis. Children’s also may share your child’s medical information as
required by your insurer or HMO to obtain payment for your child’s treatment and/or hospital
stay. Children’s also may use and disclose your child’s medical information for our health care
operations, which includes activities to improve the quality of care -- for example, for review and
training purposes.

• To provide you with appointment reminders.
• To inform you of treatment alternatives, benefits or services related to your child’s
  health that may be of interest to you. (You will have an opportunity to refuse to
  receive this information.)
• Individuals who have the authority to consent to your child’s treatment or who are
  involved in payment for treatment.
• Use in a hospital directory, which may include your child’s name, general condition
  and location in the hospital.
• To carry out payment, health care operations or other functions through business
  associates (for example, to install a new computer system).
• Public health activities including disease prevention, injury or disability; reporting
  births and deaths; reporting child abuse or neglect; reporting reactions to medications
  or product problems; notification of recalls; infectious disease control; or notifying
  government authorities of suspected abuse, neglect or domestic violence (if you agree
  or as required by law).
• Health oversight activities (for example, audits, inspections, investigations and
  licensure).
• Lawsuits and disputes.
• Law enforcement (for example, in response to a court order or subpoena).
• Coroners and medical examiners.
• Organ and tissue donation.
• Certain research projects approved by an Institutional Review Board.
• The American Red Cross (or a government disaster relief agency) if your child’s care
  is involved in a disaster relief effort.
• To prevent a serious threat to health or safety.
• To military command authorities if you are a member of the armed forces.
• National security and intelligence activities.
• Protection of the President or other authorized persons or foreign heads of state, or to
  conduct special investigations.
• To contact you or use (or disclose to a business associate) your child’s medical
  information for fundraising activities, but such information will be limited to your
  name, address, phone number, and the dates you received services at, or by,
  Children’s. Funds raised will be used to expand and improve the services and
  programs Children’s provides for the children of North Texas. (You will have an
  opportunity to refuse to receive future fundraising communications.)
• Inmates. (Medical information about children subject to correctional institution
  authority may be released to the institution.)
• Workers’ Compensation. (Your child’s medical information regarding benefits for
  work-related illnesses may be released as appropriate).
• As required by law.

Your authorization is required for other disclosures.
Except as described above, Children’s will not use or disclose your child’s medical information
unless you provide Children’s written authorization to disclose it. You may revoke your
authorization, which will be effective only after the date of your written revocation.

Is certain medical information subject to additional restrictions?
Certain types of information may be subject to additional restrictions on disclosure, such as
substance abuse treatment records, AIDS test results and psychotherapy notes.

You have rights regarding your child’s medical information.
To invoke any of the following rights, you may make a written request on the form provided by
Children’s.

Right to confidential communications. You may request to receive
communications in a certain way or at a certain location, but you must specify how or
where you wish to be contacted.

• Right to request restriction. You may request limitations on the medical
  information Children’s uses or discloses for treatment, payment or health care
  operations, but Children’s is not required to agree to your request. If we agree, we
  will comply with your request unless the information is needed to provide your child
  with emergency treatment.
• Right to confidential communications. You may request to receive
  communications in a certain way or at a certain location, but you must specify how or
  where you wish to be contacted.
• Right to inspect and copy. You have the right to inspect and copy your child’s
  medical information regarding decisions about your child’s care. Children’s may
  charge a fee for copying, mailing and supplies. Under limited circumstances, your
  request may be denied; in some cases you may request review of the denial by
  another licensed health care professional chosen by Children’s. Children’s will
  comply with the outcome of the review.
• Right to request amendment. If you believe that the medical information Children’s
  has about your child is incorrect or incomplete, you may request an amendment on
  the form provided by Children’s, which requires certain specific information.
  Children’s is not required to accept the amendment.
• Right to accounting of disclosures. You may request a list of the disclosures of your
  child’s medical information that have been made by Children’s to persons or entities
  in the past six years, but not before April 14, 2003. Such a list will not include certain
  disclosures, including disclosures made (i) to you; (ii) with your authorization; or (iii)
  for treatment, payment and health care operations. After the first request, there may
  be a charge.

• Right to a copy of this notice. You may request a paper copy of this notice at any
  time, even if you have been provided with an electronic copy. You may also obtain
  an electronic copy of this notice at the Children’s Web site, www.childrens.com.

You are not entitled access to information prohibited by the Clinical Laboratory
Improvement Amendments.

Requirements regarding this notice.
Children’s is required by law to maintain the privacy of medical information and to provide you
with this notice of our legal duties and privacy practices with respect to medical information.
Children’s will be governed by this notice for as long as it is in effect. Children’s may change this
notice, and these changes will be effective for medical information we have about your child as
well as any information Children’s receives in the future. We will provide you a copy of revised
notices upon request and make them available when you seek our services.

Complaints?
If you believe your child’s privacy rights have been violated, you may file a complaint with
Children’s or with the Secretary of the United States Department of Health and Human Services.
You will not be penalized or retaliated against in any way for making a complaint to Children’s
or the Department of Health and Human Services. 

Call Children’s Privacy and Information Security Officer at 214-456-4444 if:

• You have a privacy complaint.

• You have any questions about this notice.

• You wish to request restrictions on uses and disclosures for treatment, payment or health care
  operations.

• You wish to obtain a form to exercise your rights as described above.