Privacy Policy of Main Street Medical Care

Privacy Notice
Main Street Medical Care
Dr. David Zahaluk,
Board Certified Family Medicine & Founder
of Main Street Medical Care
Please review this notice carefully. It describes how your medical information may be used and disclosed and how you can get access to that information.


Policy Statement
This practice is omitted to maintaining the privacy of your protected health information (PHI) which includes information about your medical condition and the care and treatment you receive from the practice and other health care providers. This notice details how your PHI may be used and disclosed to third parties for purposes of your care, payment of  your care, health care operations of the practice and for other purposed permitted or required by law. This notice also detail your rights regarding your PHI.
Use or disclosure of PHI
This practice may use and/or disclose your PHI for purposes related to your care, payment for your care, and other health care operations of the practice. The following are examples of the types of uses not meant to include all possible types of use and/or disclosure.
-Care – In order to provide care to you, the practice will provide your PHI to those health care professionals, whether on the practice’s staff or not, directly involved in your care so that they may understand your medical condition and needs and provide advice or treatment (eg., your physician).For example, your physician may need to know how your condition is responding to the treatment provided by the practice.
-Payment – In order to get paid for some or all of the health care provided by the practice, the practice may provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements. For examples, the practice may need to provide your health insurance carrier with information about health care services that you received from the practice so that they practice can be properly reimbursed.
-Health Care Operations – In order for the practice to operate in accordance with the applicable law and insurance requirements and in order for the practice to provide quality and efficient care, it may be necessary for the practice to compile, use and/or disclose your PHI. For example, the practice may use your PHI in order to evaluate the performance of the practice’s personnel in providing care to you.
The practice may use and/or disclose your PHI, without a written Authorization from you, in the following instances:
1.  De-identified information – Your PHI is altered so that it does not identify you and, even without your name, cannot be used to identify you.
2.  Business Associate – To a business associate, which is someone who the practice contracts with to provide a service necessary for your treatment, payment for your treatment and health care operations (e.g., billing service or transcription service.) The practice will obtain satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI.
3.  Personal Representative – To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.
4.  Public Health Activities – Such activities include,for example, information collected by a public health authority, as authorized by law, to prevent or control disease, injury or disability. This includes reports of child abuse or neglect.
5.  Federal Drug Administration – If required by the Food and Drug Administration to report adverse events, product defects or problems or biological product deviations, or to track products, or to enable product recalls, repairs or replacements, or to conduct post marketing surveillance.
6.  Abuse, neglect or domestic violence – To a government authority if the practice is required by law to make such a disclosure it will do so if it believes that the disclosure is necessary to prevent serious harm or if the practice believes that you have been the victim of abuse, neglect or domestic violence. Any such disclosure will be made in accordance with the requirements of law, which may also involved notice to you of the disclosure.
7.  Health Oversight Activities – Such activities, which must be required by law, involve government agencies involved in oversight activities that relate to the health care system, government benefit programs, government regulatory programs and civil rights law. Those activities include relating to the community’s health care system.
8.  Judicial and administrative proceeding – For example, the practice may be required to disclose your PHI in response to a court or a lawfully issued subpoena.
9.  Law enforcement purposes – In certain instances, your PHI may have to be disclosed to a law enforcement official for law enforcement purposes. Law enforcement purposes include: (1) complying with a legal process (i.e., subpoena) or as required by law; (2) information for identification and location purposes (e.g. suspect or missing person); (3) information regarding a person who is or is suspected to be a crime victim; (4) in situations where the death of an individual may have resulted from criminal conduct; (5) in the event  of a crime occurring on the premises of the practice; and (6) a medical emergency (not on the practice’s premises) has occurred, and it appears that a crime has occurred.
10.  Coroner or Medical Examiner - The practice may disclose your PHI to a coroner or medical examiner for the purpose o identifying you or determining your cause of death, or to a funeral director as permitted by law and as necessary to carry out its duties.
11.  Organ, eye or tissue donation - If you are an organ donor, the practice may disclose your PHI to the entity to whom you have agreed to donate your organs.
12.  Research – If the practice is involved in research activities, your PHI may be used, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI such as approval of the research by an institutional review board and the requirement that protocols must be followed.
13.  Avert a threat to health or safety – The practice may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonable able to prevent or lessen the threat.
14.  Specialized government functions – When the appropriate conditions apply, the practice may use PHI of individuals who are Armed Forces personnel: (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veteran Affairs of eligibility for benefits; or (3) to a foreign military authority if you are a member of that foreign military service. The practice may also disclose your foreign military service. The practice may also disclose your PHI to authorized federal officials for conduction national security and intelligent activities including the provision of protective services to the President or others legally authorized.
15.  Inmates – The practice may disclosed your PHI to an correctional institution or a law enforcement official if you are an inmate of that correctional facility and your PHI is necessary to provide care and treatment to you or is necessary for the health and safety of other individuals or inmates.
16.  Workers’ compensation – If you are involved in a workers’ compensation claim, the practice may be required to disclose your PHI to an individual or entity that is part of the workers compensation system.
17.  Disaster  relief efforts – The practice may use or disclose your PHI to a public or private entity authorize to assist in disaster relief efforts.
18.  Required by law – If otherwise required by law, but such use or disclosure will be made in compliance with the law and limited to the requirement of the law.
Uses and/or disclosure, other than those described above, will be made only with your written authorization, which you may revoke at any time.
Appointment reminder
The practice may, from time t time, contact you to provide appointment reminders. The reminder may be in the form of a letter or postcard. The practice will try to minimize the amount of information contained in the reminder. The practice may also contact you by phone and, if you are not available, the practice will leave a message for you.
Treatment alternative/benefits
The practice may, from time to time, contact you about treatment alternatives, or other health benefits or services that may be of interest to you. 
Your rights
You have the right to:
-Revoke any authorization, in writing, at any time. To request a revocation, you must submit a written request to the practice’s privacy officer.
-Request restriction on certain use and/or disclosure of your PHI as provided by law. However, the practice is not obligated to agree to an requested restrictions. To request restriction, you must submit a written request to the practice’s privacy officer. In your written request, you must inform the practice of what information you want to limit, whether you want to limit the practice’s use or disclosure, or both, and to whom you want the limits to apply. If the practice agrees to your request, the practice will comply with your request unless the information is needed in order to provide you with emergency   treatment.
-Receive confidential communications of PHI by alternative means or at alternative locations. You must make your request in writing to the practice’s privacy officer. The practice will accommodate all reasonable requests.
-Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written request to the practice’s privacy officer. In certain situations that are defined by law, the practice may deny your request.
-Amend your PHI as provided by law. To request an amendment, you must submit a written request6 to the practice’s privacy officer. You must provide a reason that supports your request. The practice may deny your request if it is not in writing, if you do not provide a reason and support of your request, if the information to be amended was not create by the practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the practice, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the practice’s denial, you have the right to submit a written statement of disagreement. 
-Receive an accounting of discourse of your PHI as provided by law. To request an accounting, you must submit a written request to the practice’s privacy officer. The request must state a time period which may not be longer than six years and may not include the dates before April 14, 2003. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a 12 month period will be free, but the practice may charge you for the cost of providing additional lists in that same 12 month period. The practice will notify you of the costs involved and you can decide to withdraw or modify your request to the practice’s privacy officer.
-Complain to the practice, or to the Secretary of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Building, 200 Independence Avenue, S.W. Room 509F HHH Building, Washington, D.C. 20201. Or you may contact a regional office of the Office of Civil Rights, which can be found at To file a complaint with the practice, you must contact the practice’s privacy officer. All Complaints must be in writing.
-To obtain more information on, or have your question about your rights answered, you may contact the practice’s privacy officer.
Practice’s requirements
The health care office;
-Is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice of the Practice’s legal duties and privacy practices with respect to your PHI.
-Is required to abide by the terms of this privacy notice.
-Reserves the right to change the terms of this privacy notice and to make the new privacy notice provisions effective for all  of your PHI that it maintains.
-Will not retaliate against you for making a complaint.
-Must make a good faith effort to obtain from you an acknowledgement o receipt of this notice.
-Will post this privacy notice on the practice’s web site, if the practice maintains a web site.
-Will provide this privacy notice to you free of charge upon request.
Main Street Medical Care,
Dr. David Zahaluk
571 West Main St., #120
Lewisville, Tx 75057


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