Notice of Privacy Practices

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

Who will follow this notice

This notice describes Cook Children’s practices and those of:

Any health care professional authorized to enter information into your medical record;
Any volunteer we allow to help you while you are in our care; and
All Cook Children’s employees, staff and other personnel.

The following entities within Cook Children’s Health Care System will follow these practices:

W.I. Cook Foundation Inc. dba Cook Children’s Health Foundation;
Cook Children’s Medical Center;
Cook Children’s Medical Center - Prosper;
Cook Children’s Health Care System;
Cook Children’s Physician Network;
Cook Children’s Surgery Center LLC;
Cook Children’s Pediatric Surgery Center;
Cook Children’s Home Health; and
Child Study Center

These entities, sites and locations follow the terms of this notice and may share protected health information with each
other for treatment, payment or operational purposes described in this notice.

The term “you” in this notice represents either you or your child.

Your rights

When it comes to your health information, you have certain rights. This section explains your rights and some of
our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information or have it sent to another person you designate. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information that you think is incorrect or incomplete. Ask us how to do this.
We are allowed to deny a request but will provide you the reason in writing within 60 days of the request.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will approve all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment or our operations. In most cases, we are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we've shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with and why.
We will include all the disclosures except for those about treatment, payment, health care operations and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the contact information on the back page.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, DC 20201, calling 1-877-696-6775 or visiting www.hhs.gov/hipaa/filing-a-complaint.
We will not retaliate against you for filing a complaint.

Your choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for
how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will
follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends or others involved in your care.
Share information in a disaster relief situation.
Include your information in a hospital directory.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We also may share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information, unless you give us written permission:

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

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our uses and disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

We may use third party business associates to perform these functions. To safeguard your protected health information, Cook Children's has agreements with these third parties that require them to appropriately protect your information.

How else can we use or share your health information? We are allowed or required to share your information in other
ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many
conditions in the law before we can share your information for these purposes. For more information, see:
hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease.
Helping with product recalls.
Reporting adverse reactions to medications.
Reporting suspected abuse, neglect or domestic violence.
Preventing or reducing a serious threat to anyone's health or safety.

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law, or others who request it if sharing is required by the rules prohibiting information blocking.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner or funeral director when an individual dies.

Address workers' compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers' compensation claims.
For law enforcement purposes or with a law enforcement official.
With health oversight agencies for activities authorized by law.
For special government functions such as military, national security and presidential protective services.

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order or in response to a subpoena.

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 comprised 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. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information, see: https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the terms of 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 upon request, in our office and on our website.

Non-discrimination policy

Cook Children's complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Cook Children's provides free aids and services to help people with disabilities communicate effectively with us, including qualified sign language interpreters and written information in other formats. Cook Children's also provides free language services to people whose primary language is not English, including qualified interpreters and information written in other languages.

If you need these services, contact Cook Children's Language Services at 682-885-4000. If you believe Cook Children's has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by contacting Cook Children's Civil Rights Coordinator, 801 7th Ave., Fort Worth, TX 76104, 682-885-8020, civilrights@cookchildrens.org. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD). Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html.

Language assistance services

Contact information

Cook Children's
801 7th Ave.
Fort Worth, TX 76104

Website: cookchildrens.org

Privacy Officer
Phone: 682-885-7822
Email: privacyofficer@cookchildrens.org