THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
HEALTH NETWORK PRIVACY NOTICE
Effective April 14, 2003
At Galaxy Health Network, we respect the confidentiality
of your health information and will protect your
information in a responsible and professional manner.
We are required by law to maintain the privacy of your
health information and to provide you with this notice.
This notice explains how we use information about you
and when we can share that information with others. It
also informs you of your rights with respect to your
health information and how you can exercise those
When we talk about protected information or protected
health information in this notice we mean the following:
Protected Health Information means all individually
identifiable health information transmitted or
maintained by a covered entity, regardless of form. The
final rule defines protected health information to be
individually identifiable health information that is:
transmitted by electronic media;
maintained in any medium described in the definition
of electronic media or;
transmitted or maintained in any other form or
following are ways we may use or share information about
We may use the information to help pay your medical
bills that have been submitted to us by doctors and
hospitals for payment.
We may share your information with your doctors or
hospitals to help them provide medical care to you.
For example, if you are in the hospital, we may give
them access to any medical records sent to us by
We may use or share your information with others to
help manage your health care. For example, we might
talk to your doctor to suggest a disease management
or wellness program that could help improve your
We may share your information with others who help
us conduct our business operations.
We will not share your information with these
outside groups unless they agree to keep it
We may use or share your information for certain
types of public health or disaster relief efforts.
We may use or share your information to send you a
reminder if you have an appointment with your
We may use or share your information to give you
information about alternative medical treatments and
programs or about health related products and
services that you may be interested in. For
example, we might send you information about smoking
cessation or weight loss programs.
We may use or share your information to share
information with a health plan through which you
receive health benefits.
There are also state and federal laws that may require
us to release your health information to others. We may
be required to provide information for the following
We may report information to state and federal
agencies that regulate us such as the US Department
of Health and Human Services and the [insert name of
state regulatory agency];
We may share information for public health
activities. For example, we may report
information to the Food and Drug Administration for
investigating or tracking of prescription drug and
medical device problems;
We may report information to public health agencies if
we believe there is a serious health or safety threat;
We may share information with a health oversight agency
for certain oversight activities (for example, audits,
inspections, licensure and disciplinary actions);
We may provide information to a court or administrative
agency (for example, pursuant to a court order, search
warrant or subpoena);
We may report information for law enforcement purposes.
For example, we may give information to a law
enforcement official for purposes of identifying or
locating a suspect, fugitive, material witness or
We may report information to a government authority
regarding child abuse, neglect or domestic violence;
We may share information with a coroner or medical
examiner to identify a deceased person, determine a
cause of death, or as authorized by law;
We may use or share information for procurement, banking
or transplantation of organs, eyes, or tissue;
We may share information relative to specialized
government functions, such as military and veteran
activities, national security and intelligence
activities, and the protective services for the
President and others;
We may report information on job-related injuries
because of requirements of your state worker
If one of the above reasons does not apply,
get your written permission to use or disclose your
If you give us written
permission and change your mind
you may revoke your
written permission at any time.
The following are your rights with respect to your
health information. If you would like to exercise the
following rights, please contact us at 800-975-3322.
You have the
right to ask us to restrict
how we use or disclose your information for treatment,
payment, or health care operations. You also have the
right to ask us to restrict information that we have
been asked to give to family members or to others who
are involved in your health care or payment for your
health care. Please note that while we will try to
honor your request, we are not required to agree to
You have the right to ask to receive confidential
of information. For example, if you believe that you
would be harmed if we send your information to your
current mailing address (for example, in situations
involving domestic disputes or violence), you can ask us
to send the information by alternative means (for
example, by fax) or to an alternative address. We will
accommodate your reasonable requests as explained
You have the right to inspect and obtain a copy
of information that we maintain about you
in your designated record set. A designated record set
Designated Record Set means a group of records
maintained by or for a covered entity that is:
The medical records and billing records about
individuals maintained by or for a covered health
The enrollment, payment, claims adjudication, and
case or medical management record systems maintained
by or for a health plan or;
Used, in whole or in part, by or for the covered
entity to make decisions about individuals.
you do not have the right to access certain types of
information and we may decide not to provide you with
copies of the following information:
contained in psychotherapy notes;
compiled in reasonable anticipation of, or for use
in a civil criminal or administrative action or
subject to certain federal laws governing biological
products and clinical laboratories.
In certain other situations, we may deny your request to
inspect or obtain a copy of your information. If we
deny your request, we will notify you in writing and may
provide you with a right to have the denial reviewed.
You have the right to ask us to make changes
to information we maintain about you in your designated
record set. These changes are known as amendments. We
may require that your request be in writing and that you
provide a reason for your request. We will respond to
your request no later than 60 days after we receive it.
If we are unable to act within 60 days, we may extend
that time by no more than an additional 30 days. If we
need to extend this time, we will notify you of the
delay and the date by which we will complete action on
If we make the amendment, we will notify you that it was
made. In addition, we will provide the amendment to any
person that we know has received your health
information. We will also provide the amendment to other
persons identified by you.
If we deny your request to amend, we will notify you in
writing of the reason for the denial. The denial will
explain your right to file a written statement of
disagreement. We have a right to respond to your
statement. However, you have the right to request that
your written request, our written denial and your
statement of disagreement be included with your
information for any future disclosures.
You have the right to receive an accounting
of certain disclosures of your information made by us
during the six years prior to your request. Please note
that we are not required to provide you with an
accounting of the following information:
We may require that your request be in writing. We will
act on your request for an accounting within 60 days.
We may need additional time to act on your request. If
so, we may take up to an additional 30 days. Your first
accounting will be free. We will continue to provide
you with one free accounting upon request every 12
months. If you request an additional accounting within
12 months of receiving your free accounting, we may
charge you a fee. We will inform you in advance of the
fee and provide you with an opportunity to withdraw or
modify your request.
You have a right to receive a copy of this notice
upon request at any time.
You can also view a copy of the notice on our web site
at www.galaxyhealth.net. Should any of our privacy
practices change, we reserve the right to change the
terms of this notice and to make the new notice
effective for all protected health information we
maintain. Once revised, we will provide the new
notice to you by direct mail and post it on our website.
If you have any questions about this notice or about how
we use or share information, please contact Dan Shadle
at (800) 975-3322. That office is open Monday through
Friday from 9:00 a.m. to 5:00 p.m. You can also send us
questions by e-mail at firstname.lastname@example.org.
If you believe your privacy rights have been violated,
you may file a complaint with us by contacting Galaxy
Health Network, attn: Dan Shadle, P.O. Box 201425,
Arlington, Texas 76006. You may also notify the
Secretary of the U.S. Department of Health and Human
Services of your compliant.
WE WILL NOT TAKE ANY
ACTION AGAINST YOU FOR FILING A COMPLAINT.
Galaxy Health Network
631 106th Street
Arlington, Texas 76011