Notice of Privacy Practices

Introduction to Privacy Practices
This Notice identifies the general ways your protected health information (“PHI”) as defined under the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, as amended (“HIPAA”), can be used or disclosed. PHI includes certain pieces of your information found in your medical and billing records. PHI includes information, whether oral, written or recorded in electronic form, that is created or received by us and relates to your past, present or future physical or mental health conditions, provision of health care, or the payment for health care services. This information can be transmitted or maintained in any form by Houston Methodist.

This Notice describes your legal rights regarding your PHI. It also informs you of our legal duties and privacy practices. If you receive services by your physician or a health care provider at a different location, there may be different health information privacy policies or notices, and there will be different contact information.

Houston Methodist organizations and their medical staffs participate in an Organized Health Care Arrangement under HIPAA for the purpose of sharing PHI for treatment, payment and health care operations. Houston Methodist hospitals and their respective medical staff members are independently responsible for complying with this notice.

OUR LEGAL DUTIES
We are required by law to keep your PHI private; provide you with this Notice of our legal duties and privacy practices with respect to your PHI and notifications following a breach of unsecured PHI; and follow the terms of this Notice as long as it is in effect. If we revise this Notice, we will follow the terms of the revised notice, as long as it is in effect.
How We May Use and Disclose Your Health Information
The following information describes how we are permitted, or required by law, to use and disclose your PHI. Not every use or disclosure in a category will be listed.

Treatment: We may use or disclose your PHI to a physician or other health care provider in order to provide care and treatment to you. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. Different departments at Houston Methodist also may share information about you in order to coordinate the different services you receive, such as lab work, X-rays and prescriptions. We also may disclose PHI about you to those who may be involved in your health care outside of Houston Methodist, such as physicians and others who provide you with follow-up care and medical equipment or product suppliers. We may contact you to coordinate care after discharge, provide appointment reminders and to provide you with information about health-related benefits and services at Houston Methodist, or treatment alternatives that may be of interest to you.

Payment: We may use or disclose your PHI to obtain payment for services we provide to you. We may disclose your health information to another health care provider or entity. For example, Houston Methodist may need to provide your health plan with information about surgery you received so that your health plan will pay Houston Methodist or reimburse you for the surgery. Houston Methodist also will tell your health plan about a treatment you are going to receive to obtain the health plan’s prior approval for this treatment or to determine whether your plan will cover the treatment.

Health Care Operations: We may use or disclose PHI about you to support the programs and activities of Houston Methodist such as quality and service improvement; health care delivery review; staff performance evaluation; competence or qualification review of health care professionals; education and training of physicians and other health care providers; and business planning and development, business management and general administrative activities. We use this information to continuously improve the quality of care for all patients we serve. For example, we may combine health information about many patients to evaluate the need for new services or treatments. We may disclose information for educational purposes to doctors, nurses and other students. And we may combine health information we have with that of other facilities to see where we can make improvements.

Additionally, we may share your PHI with other health care providers and payors for certain of their business operations if the information is related to a relationship the provider or payor currently has or previously had with you, and if the provider or payor is required by federal law to protect the privacy of your PHI. We may also “de-identify” or anonymize your PHI, by removing your name, address, and any other data elements that might be used to identify you; we may use or disclose any resulting de-identified or anonymized information for any reason, it will no longer be subject to this notice or your rights described below.

As Required by Law: We will disclose PHI about you when required to do so by federal, state or local law or regulations, including disclosures that may be required under the 21st Century Cures Act. For example, in the event you are admitted, discharged or transferred to or from Houston Methodist, we may be required to notify certain other providers who may be able to care for you.

Your Houston Methodist Electronic Health Record, the Houston Methodist Care Everywhere Health Information Exchange and Other Record Sharing: We may make your PHI available electronically to other care providers such as hospitals, laboratories and physicians involved in your care who request your PHI. The purpose of this exchange of information is to support the delivery of safer, better coordinated patient care. We use an electronic health record system across the Houston Methodist system. This allows your PHI to be easily shared and accessed by all your Houston Methodist providers, including hospitals and physicians associated with Houston Methodist.

Another method for sharing this information is through the use of a health information exchange. Participation in the information exchange is voluntary. If you do not want your Houston Methodist health information to be accessible electronically to health care providers through Houston Methodist Care Everywhere, you may submit a signed opt-out (nonparticipation) form, available online at houstonmethodist.org/care-everywhere or from your registration representative. If you decide not to participate, health care providers will not be able to access your PHI electronically through Houston Methodist Care Everywhere.

Houston Methodist also participates in the Community Connect EHR system, allowing physicians and other providers to share access with Houston Methodist’s electronic health record system, so that multiple providers can access and update a single medical record for each individual patient.

Authorization for Disclosures: We create, receive, maintain and, in some instances, disclose your PHI in physical or electronic format. We will not use or disclose your PHI, except as described in this document or as otherwise permitted or required by law, unless you authorize us, in writing, to do so. You may give us written authorization to disclose your PHI, including in electronic format, to anyone for any purpose. Houston Methodist may use electronic or other means to satisfy your request for the authorized disclosure. You can revoke an authorization at any time, in writing. If you revoke an authorization, we will no longer use or disclose your PHI for the purpose covered by the authorization. However, we are unable to take back any uses or disclosures already made with your authorization. Specific examples of uses or disclosures requiring authorization include: use of psychotherapy notes, marketing activities, the sale of your PHI and certain uses and disclosures for which we are compensated.

Reproductive Health Care Privacy: If we determine that you have or are lawfully seeking, obtaining, providing or facilitating reproductive health care, we are prohibited from using or disclosing your PHI to conduct a criminal, civil or administrative investigation, or impose criminal, civil or administrative liability, against you or any person for the mere act of seeking, obtaining, providing or facilitating such lawful reproductive health care. We are also prohibited from identifying you or any person for such purposes. For example, we cannot disclose your PHI or identify you to facilitate in a criminal investigation against you for lawfully obtaining birth control or abortion care. “Reproductive health care” means health care, as defined by HIPAA, that affects the health of an individual in all matters relating to the reproductive system and to its functions and processes. This section is only applicable if required by the HIPAA Privacy Rule to Support Reproductive Health Care Privacy, as in effect or as may be amended.

Attestations Regarding Reproductive Health Care: We may not use or disclose your PHI relating to reproductive health care for purposes of health oversight activities, judicial and administrative proceedings, law enforcement purposes, or coroners and medical examiners without taking reasonable steps to obtain a valid attestation from the requestor that such request is lawful. For example, we may not disclose your PHI regarding a lawfully obtained abortion for the purpose of a judicial proceeding without taking reasonable steps to obtain attestation that they will not use your PHI for a prohibited purpose.

Hospital Directory: Unless you instruct otherwise, we may disclose your name, general condition and location in the hospital to your friends, family and others who ask for you by name. Unless you instruct otherwise, we may provide your name, location in the hospital and religious affiliation to clergy members of your faith or tradition upon their request.

Family and Friends: We may use or disclose information to notify or assist in notifying a family member, personal representative or other person responsible for your care, of your location and general condition. We may also disclose PHI to a family member, other relative, close personal friend or any other person you identify, if the information is relevant to that person’s involvement with your care or payment for your care.

Fundraising: We may use or disclose PHI and, if applicable, Part 2 (defined below) records about you to our business associates or institutionally related foundations, like Houston Methodist Hospital Foundation, to assist us in our fundraising activities. Rest assured, we will never sell your PHI for monetary or in-kind remuneration without your prior authorization. You have the right to opt out of fundraising communications at any time by calling 832.667.5816 or emailing donor@houstonmethodist.org and following the provided instructions. Any such communication from us will have clear and conspicuous instructions on how to opt out of future fundraising communications.

Communications: We may use or disclose your PHI to communicate with you via newsletters, mailings or other means including regarding treatment options, health-related information, disease-management programs, wellness programs, or other community-based initiatives or activities in which Houston Methodist participates. Rest assured, we will never sell your PHI for monetary or in-kind remuneration without your prior authorization. If we receive any financial compensation for such communications (with limited permitted exceptions), we will obtain your authorization prior to sending the communication and your authorization can be revoked at any time. Additionally, if we provide you with certain marketing communications as limited under HIPAA, we will obtain your authorization prior to sending such communications and your authorization can be revoked at any time. We may also send you other informational communications that you can opt out from receiving by visiting houstonmethodist.org/opt-out or by calling 713.790.3333.

Public Health and Safety: We may use or disclose health information, as authorized or required by local, state or federal law, for the following purposes deemed to be in the public interest or benefit:

 

  • To report certain diseases and wounds, births and deaths, and suspected cases of abuse, neglect or domestic violence
  • To help identify, locate or report criminal suspects, crime victims, missing persons, suspicious deaths or criminal conduct on Houston Methodist’s premises
  • To respond to a court order, subpoena or other judicial process
  • To assist federal disaster relief efforts
  • To enable product recalls, repairs or replacements
  • To respond to an audit, inspection or investigation by a health-related government agency
  • To assist in federal intelligence, counterintelligence and national security issues
  • To facilitate organ and tissue donations
  • To assist coroners, medical examiners and funeral directors
  • To respond to a request from a jail or prison regarding an inmate’s health or medical treatment
  • To respond to a request from your military command authority (if you are a member or veteran of the armed forces)
  • To provide information to a workers’ compensation program

 

Business Associates: There are some services provided at Houston Methodist through contracts with business associates. When these services are contracted, we will disclose your PHI to the business associate so they can perform the job we have asked them to do. However, business associates are required by federal law to appropriately safeguard your PHI.

Research: We may disclose your PHI to researchers after approval by an institutional review board (IRB) in preparation for a research study, to recruit research subjects or for a research study. The IRB reviews research proposals and establishes protocols to protect your safety and the privacy of your PHI.

Protections for Future Redisclosures: Once we disclose your PHI, that information may be redisclosed by the recipient and is no longer subject to HIPAA and its protections.

Special Privacy Protections for Part 2 Alcohol and Drug Abuse Information: Certain substance use disorder records subject to 42 C.F.R. Part 2 (“Part 2”) have special privacy protections. Part 2 records are limited to those created by certain federally assisted programs that provide substance use disorder diagnosis, treatment or referrals. If we receive or maintain Part 2 records about you, we will generally only use or disclose such records for the purposes discussed in this Notice if you give, or have given, your prior written consent. We will not use or disclose Part 2 records or testimony relaying the content of such records in any legal proceedings against you, unless you give, or have given, your written consent or we receive a court order and you have received notice and opportunity to be heard. Such court order must be accompanied by a subpoena or other legal requirement compelling disclosure. We may also disclose Part 2 records or such information without your consent if medical personnel need the information to meet a medical emergency; qualified personnel use the information for the purpose of conducting scientific research, certain management audits, financial audits or program evaluations; or it is necessary to report a crime or a threat to commit a crime, or to report abuse or neglect as required by law.

Your Health Information Rights
Your medical record is the property of Houston Methodist (the health care practitioner or facility that compiled it). You have the following rights, with certain exceptions, regarding the health information that is created about you at Houston Methodist.

You have the right to a paper copy of this notice. In addition, you may visit our website at houstonmethodist.org/patient-privacy to obtain a copy of this notice.

Confidential Communications: You have the right to request that we communicate PHI to you by an alternate means or location other than your home address and telephone number. Your request must be made in writing to Houston Methodist’s contact person listed below, and must specify how or where you wish to be contacted. We will try to accommodate your request for alternate communications. If you request an alternate means of communication, that request also should be communicated by you to all of your physicians, including your private physician.

Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information to a family member about a surgery you had. To request a restriction, you must make your request in writing to the contact person listed below. We are not required to agree to your request. If we do agree, our agreement must be in writing, and we will comply with your request unless the information is needed to provide you emergency treatment.

Additionally, you have the right to request that we not use or disclose PHI to a health plan for purposes of payment or health care operations (not for treatment), if the PHI pertains solely to a health care item or service that has been paid for out of pocket and in full. Your request for restriction must be submitted in writing to our contact person listed below. In this case, Houston Methodist must honor your request. However, you should be aware that such restrictions may have unintended consequences, particularly if other providers need to know that information, such as a pharmacy filling a prescription. It will be your obligation to notify any such other providers of this restriction. Additionally, such a restriction may impact your health plan’s decision to pay for related care that you may not want to pay for out of pocket (and which would not be subject to the restriction).

Access: You have the right to review and obtain a copy of your PHI, with certain exceptions. Usually, this includes access to your medical and billing records, but does not include psychotherapy notes. Your request to review or obtain a copy of your health information must be in writing to our contact person listed below. You will be charged fees as authorized by law. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format.

Amendment: If you feel that the PHI we have about you is incorrect or incomplete, you have the right to ask for an amendment of that information. You have the right to request an amendment for as long as the information is kept by or for us. Your request for an amendment must be made in writing to our listed contact person below, and include a reason that supports your request.

Accounting of Disclosures: You have the right to receive a list of certain disclosures that we have made within the last six years of your PHI. Your request for an accounting must be in writing to our listed contact person below, and must state a time period for which you want an accounting. You may request one accounting free of charge within a 12-month period. A fee will be charged for additional lists within this same time period.

Breach Notification: In certain instances, you have the right to be notified in the event that we, or one of our business associates, discover an inappropriate use or disclosure of your PHI. Notice of any such use or disclosure will be made in accordance with state and federal requirements.

Revisions of this Notice: We reserve the right to change this Notice, and the right to make the new provisions effective for all PHI we currently maintain, as well as any PHI we receive in the future. If we make a major change to this Notice, the revised Notice will be posted at the Houston Methodist locations listed above and on our website. In addition, a paper copy of the revised Notice will be available upon request.

To Report a Complaint: If you believe your HIPAA privacy rights have been violated, you can file a complaint with us by writing to the Business Practices Officer at the relevant location listed below or with the Secretary of the United States Department of Health and Human Services. There will not be any penalty or retaliation against you for making a complaint to us or to the Department of Health and Human Services.
Contact Information
Contact Person: If you have any questions or need information regarding our legal duties and privacy practices, or how to exercise any of your HIPAA rights listed in this Notice, please contact the business practices officer for the location of interest:

Houston Methodist Hospital – Texas Medical Center
Business Practices Officer
6565 Fannin St., Houston, TX 77030
713.790.3311

Houston Methodist Baytown Hospital
Business Practices Officer
4401 Garth Rd., Baytown, TX 77521
281.420.8600

Houston Methodist Clear Lake Hospital
Business Practices Officer
18300 Houston Methodist Dr., Nassau Bay, TX 77058
281.523.2000

Houston Methodist Continuing Care Hospital
Business Practices Officer
701 S. Fry Rd., Katy, TX 77450
281.599.5700

Houston Methodist Cypress Hospital
Business Practices Officer
24500 Northwest Fwy., Cypress, TX 77429
346.618.2000

Houston Methodist Sugar Land Hospital
Business Practices Officer
16655 Southwest Fwy., Sugar Land, TX 77479
281.274.7000

Houston Methodist The Woodlands Hospital
Business Practices Officer
17201 Interstate 45 S., The Woodlands, TX 77385
936.270.2000 

Houston Methodist West Houston Hospital
Business Practices Officer
18500 Katy Fwy., Houston, TX 77094
832.522.1000

Houston Methodist Willowbrook Hospital
Business Practices Officer
18220 State Hwy. 249, Houston, TX 77070
281.737.1000

Houston Methodist Primary Care Group
Business Practices Officer
1130 Earle St., Houston, TX 77030
713.383.5129

Houston Methodist Specialty Physician Group
Business Practices Officer
1130 Earle St., Houston, TX 77030
713.383.5129

Houston Methodist Surgery Center
Business Practices Officer
1130 Earle St., Houston, TX 77030
713.383.5129
 
 

Effective: March 17, 2025
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