Notice of Privacy Practices

Last updated: October 27, 2020

Uses and Disclosures of PHI

The Kingsley Clinic may use and disclose your PHI in the following ways:

1. Treatment, Payment and Healthcare Operations. The Kingsley Clinic is permitted to use and disclose your PHI for purposes of (a) treatment, (b) payment and (c) healthcare operations. For example:
   • Treatment. The Kingsley Clinic may disclose your PHI to another physician or healthcare provider for purposes of a visit or in connection with the provision of follow-up treatment.
   • Payment. The Kingsley Clinic may use and disclose your PHI to your health insurer or health plan in connection with the processing and payment of claims and other charges.
   • Healthcare Operations. The Kingsley Clinic may use and disclose your PHI in connection with its healthcare operations, such as providing customer services and conducting quality review assessments. The Kingsley Clinic may engage third parties to provide various services for The Kingsley Clinic. If any such third party must have access to your PHI in order to perform its services, The Kingsley Clinic will require that third party to enter an agreement that binds the third party to the use and disclosure restrictions outlined in this Notice.

2. Authorization. The Kingsley Clinic is permitted to use and disclose your PHI upon your written authorization, to the extent such use or disclosure is consistent with your authorization. You may revoke any such authorization at any time. To authorize The Kingsley Clinic to disclose your PHI to a third party, download the HIPAA Authorization to Disclose Protected Health Information here and mail it to the address listed on the form.
3. As Required by Law. The Kingsley Clinic may use and disclose your PHI to the extent required by law.

Additional Circumstances

The following categories describe unique circumstances in which The Kingsley Clinic may use or disclose your PHI:

1. 1. Public Health Activities. The Kingsley Clinic may disclose your PHI to public health authorities or other governmental authorities for purposes including preventing and controlling disease, reporting child abuse or neglect, reporting domestic violence and reporting to the Food and Drug Administration regarding the quality, safety and effectiveness of a regulated product or activity. The Kingsley Clinic may, in certain circumstances disclose PHI to persons who have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
   2. Health Oversight Activities. The Kingsley Clinic may disclose your PHI to a health oversight agency for authorized activities such as audits, investigations, inspections, licensing and disciplinary actions relating to the healthcare system or government benefit programs.
   3. Judicial and Administrative Proceedings. The Kingsley Clinic may disclose your PHI, in certain circumstances, as permitted by applicable law, in response to an order from a court or administrative agency, or in response to a subpoena or discovery request.
   4. Law Enforcement. The Kingsley Clinic may, under certain circumstances, disclose your PHI to a law enforcement official, such as for purposes of identifying or locating a suspect, fugitive, material witness or missing person.
   5. Decedents. The Kingsley Clinic may, under certain circumstances, disclose PHI to coroners, medical examiners and funeral directors for purposes such as identification, determining the cause of death and fulfilling duties relating to decedents.
   6. Organ Procurement. The Kingsley Clinic may, under certain circumstances, use or disclose PHI for the purposes of organ donation and transplantation.
   7. Research. The Kingsley Clinic may, under certain circumstances, use or disclose PHI that is necessary for research purposes.
   8. Threat to Health or Safety. The Kingsley Clinic may, under certain circumstances, use or disclose PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
   9. Specialized Government Functions. The Kingsley Clinic, may in certain situations, use and disclose PHI of persons who are, or were, in the Armed Forces for purposes such as ensuring proper execution of a military mission or determining entitlement to benefits. The Kingsley Clinic may also disclose PHI to federal officials for intelligence and national security purposes.

Your Rights Regarding Your PHI

You have the following rights regarding the PHI maintained by The Kingsley Clinic:

1. Confidential Communication. You have the right to receive confidential communications of your PHI. You may request that The Kingsley Clinic communicate with you through alternate means or at an alternate location, and The Kingsley Clinic will accommodate your reasonable requests. You must submit your request in writing to The Kingsley Clinic. To submit such a request, download and fill out the request form here and either email the request to support@thekingsleyclinic.com or mail it to the address listed on the form.

2. Restrictions. You have the right to request restrictions on certain uses and disclosures of PHI for treatment, payment or healthcare operations. You also have the right to request that The Kingsley Clinic restrict its disclosures of PHI to only certain individuals involved in your care or the payment of your care. You must submit your request in writing to The Kingsley Clinic. The Kingsley Clinic is not required to comply with your request. However, if The Kingsley Clinic agrees to comply with your request, it will be bound by such agreement, except when otherwise required by law or in the event of an emergency. To submit such a request, download and fill out the request form here and either email the request to support@thekingsleyclinic.com or mail it to the address listed on the form.
3. Inspection and Copies. You have the right to inspect and copy your PHI. You must submit your request in writing to The Kingsley Clinic. The Kingsley Clinic may impose a fee for the costs of copying, mailing, labor and supplies associated with your request. The Kingsley Clinic may deny your request to inspect and/or copy your PHI in certain limited circumstances. If that occurs, The Kingsley Clinic will inform you of the reason for the denial, and you may request a review of the denial. To request access to your PHI, download the Request to Access PHI Form here and either email the request to support@thekingsleyclinic.com or mail it to the address listed on the form.
4. Amendment. You have a right to request that The Kingsley Clinic amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is maintained by The Kingsley Clinic. You must submit your request in writing to The Kingsley Clinic and provide a reason to support the requested amendment. The Kingsley Clinic may, under certain circumstances, deny your request by sending you a written notice of denial. If The Kingsley Clinic denies your request, you will be permitted to submit a statement of disagreement for inclusion in your records. To make a request to amend PHI, download the Request to Amend PHI form here and either email the request to support@thekingsleyclinic.com or mail it to the address listed on the form.
5. Accounting of Disclosures. You have a right to receive an accounting of all disclosures The Kingsley Clinic has made of your PHI. However, that right does not include disclosures made for treatment, payment or healthcare operations, disclosures made to you about your treatment, disclosures made pursuant to an authorization, and certain other disclosures. You must submit your request in writing to The Kingsley Clinic and you must specify the time period involved (which must be for a period of time less than six years from the date of the disclosure). Your first accounting will be free of charge. However, The Kingsley Clinic may charge you for the costs involved in fulfilling any additional request made within a period of 12 months. The Kingsley Clinic will inform you of such costs in advance, so that you may withdraw or modify your request to save costs. To make a request for an accounting of disclosures, download the Request for an Account of Disclosures Form here and either email the request to support@thekingsleyclinic.com or mail it to the address listed on the form.
6. Breach Notification. You have the right to be notified in the event that The Kingsley Clinic (or a Kingsley Clinic Business Associate) discovers a breach of unsecured PHI.
7. Paper Copy. You have the right to obtain a paper copy of this Notice from The Kingsley Clinic at any time upon request. To obtain a paper copy of this notice, please contact the Privacy Officer by writing to: Privacy Officer, The Kingsley Clinic 14180 Dallas Parkway suite 620, Dallas, TX 75254 or sending an email to support@TheKingsleyClinic.com.
8. Complaint. You may complain to The Kingsley Clinic and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. To file a complaint with The Kingsley Clinic, you must submit a statement in writing to: Privacy Officer, The Kingsley Clinic 14180 Dallas Parkway suite 620, Dallas, TX 75254 or sending an email to support@TheKingsleyClinic.com. The Kingsley Clinic will not retaliate against you for filing a complaint.
9. Further Information. If you would like more information about your privacy rights, please send an email to the Privacy Officer at support@TheKingsleyClinic.com.