Shai M. Rozen, M.D., F.A.C.S.
1801 Inwood Road
Dallas, TX 75390
Phone: (214) 645-2353
Monday–Friday: 8 a.m.–5 p.m.
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, how you can get access to this information, your rights concerning your health information and our responsibilities to protect your health information.
Please review it carefully.
When is the notice effective?
This notice became effective on April 14, 2003. UT Southwestern reserves the right to change this notice after the effective date. We reserve the right to make the revised notice apply for all health information that we already have about you, as well as any information we receive in the future. This is the current notice. (Last revision: November 2019)
To whom does this notice apply?
This notice applies to:
- UT Southwestern’s workforce, students, and trainees.
- All departments, clinics, and hospitals of UT Southwestern.
- Any member of a volunteer group who may help you while you are seeking health care at UT Southwestern.
- Physicians who are members of the University Hospital’s medical staff including, but not limited to, The University of Texas Southwestern Medical Center physicians.
What are our responsibilities to you?
Your health information is personal. We are required by law to protect the privacy of your health information and will only release your health information as allowed by law or with special written permission (authorization) from you. We use the minimal amount of information needed to do our work. Only those who need your health information to provide services are allowed to use it. UT Southwestern protects your information whether verbal, on paper or electronic.
How do we use and release your health information?
UT Southwestern primarily maintains your health information in a secure electronic format. Your health information will most often be used, shared, or disclosed electronically. The following section explains some of the ways we are permitted to use and release health information without authorization from you.
Use and release of your health information without your authorization:
While we are providing you with health care services, we may need to share your health information with other health care providers or other individuals who are involved in your treatment. Examples include doctors, hospitals, pharmacists, therapists, nurses, and labs that are involved in your care. We may provide proof of immunizations to schools for admission purposes with your agreement.
UT Southwestern may need to share a limited amount of your health information to obtain or provide payment for the health care services provided to you. Examples include:
- Eligibility – UT Southwestern may contact the company or government program that will be paying for your health care. This helps us determine if you are eligible for benefits, and if you are responsible for paying a co-payment or deductible.
- Claims – UT Southwestern and businesses we work with share health information for billing and payment purposes. For example, your doctor must submit a claim form to be paid, and the claim form must contain certain health information.
Health Care Operations Purposes
UT Southwestern may need to share your health information in the course of conducting health care business activities that are related to providing health care to you. Examples include:
- Quality Improvement Activities – UT Southwestern may use and release health information to improve the quality or the cost of care, including population health activities. This may include reviewing the treatment and services provided to you. This information may be shared with those who pay for your care, or with other agencies that review this data.
- Health Promotion and Disease Prevention – We may use your health information to tell you about disease prevention and health care options. For instance, we may send you health care information on issues such as women’s health, cancer, or asthma.
- Fund-Raising Purposes – We may contact you for fundraising purposes to support UT Southwestern in its mission to provide quality health care, research, and education. You may opt out of receiving fundraising communication. If you do not want UT Southwestern to contact you about fund-raising efforts, please notify UT Southwestern Medical Center, Office of Development, 5323 Harry Hines Blvd., Dallas, TX 75390-9009 or complete the opt out form.
- Marketing Purposes – We may use your health information to provide prescription refill reminders, to communicate about your current prescriptions, to communicate about a health related service or product which is covered by your health plan, or about treatment alternatives for your care coordination. No authorization is required if we have a face-to-face communication with you about a service or product or if UT Southwestern provides you with a promotional gift of small value.
- Business Associates – There are some services provided at UT Southwestern through contracts with Business Associates such as medical transcription services and record storage companies. Business Associates are required by Federal law to protect your health information.
- Audits – UT Southwestern may use or release your health information to make sure that its business practices comply with the law and with our policies. Examples include audits involving quality of care, medical bills, or patient confidentiality.
- Students and Trainees – Students and other trainees may access your health information as part of their training and educational activities at UT Southwestern.
- Business Activities – We may use or release your health information to perform internal business activities. Examples include business planning, computer systems maintenance, legal services, and customer service.
- Health Information Exchange (HIE). We participate in electronic health exchanges, where we may share information that we obtain or create about you with other health care providers or other health care entities, as permitted by law. Exchange of health information through HIEs can provide faster access, better coordination of care, and assist providers in making more informed decisions. You may opt out of sharing your information through the HIEs we participate in by contacting the UT Southwestern Privacy Office. Please also note that UT Southwestern is not able to manage restrictions on disclosures of your health information through its participation in HIEs. Should you wish to restrict your information from a particular individual or entity and UT Southwestern grants your restriction, you should elect to opt out of the HIE(s) in order to protect your restriction.
- Required By Law – Sometimes we must report some of your health information to legal officials or authorities, such as law enforcement officials, court officials, governmental agencies, or attorneys. Examples include reporting suspected abuse or neglect, reporting domestic violence or certain physical injuries, or responding to a court order, subpoena, warrant, or lawsuit request.
- Public Health Activities – We may be required to report your health information to authorities to help prevent or control disease, injury, or disability. Examples include reporting certain diseases, injuries, birth or death information, information of concern to the Food and Drug Administration, or information related to child abuse or neglect. We may also have to report to your employer certain work-related illnesses and injuries so that your workplace can be monitored for safety.
- Health Oversight Agencies – We may be required to release health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system, or for governmental benefit programs.
- Activities Related to Death – Privacy protections do not apply to the medical record 50 years after death. We may be required to release health information to coroners, medical examiners, and funeral directors so they can carry out their duties related to your death. We may release health information to family members and others who were involved in your care or payment for care after your death.
- Organ, Eye or Tissue Donation – In the event of your death, we may release your health information to organizations involved with obtaining, storing or transplanting organs, eyes or tissue to determine your donor status.
- Research Purposes – At times, we may use or release health information about you for research purposes. However, all research projects require a special approval process before they begin. This process may include asking for your authorization. In some instances, your health information may be used or released for a research purpose without your authorization in accordance with law. Our researchers may use your health information to identify and contact you as a potential study participant.
- To Avoid a Serious Threat to Health or Safety – As required by law and standards of ethical conduct, we may release your health information to the proper authorities if we believe, in good faith, that such release is necessary to prevent or minimize a serious and/or approaching threat to anyone’s health or safety.
- Military, National Security, or Incarceration/Law Enforcement Custody – We may be required to release your health information to the proper authorities so they may carry out their duties under the law. This may involve the military, national security or intelligence activities, or if you are in the custody of law enforcement officials.
- Workers’ Compensation – We may be required to release your health information to the appropriate persons to comply with the laws related to workers’ compensation or other similar programs that provide benefits for work-related injuries or illness.
- Persons Involved in Your Care – In certain situations, we may release health information about you to persons involved in your care, such as friends or family members, or those who help pay for your care. You have the right to approve such releases, unless you are unable to function, or if there is an emergency.
- Notification/Disaster Relief Purposes – In certain situations, we may share your health information with the American Red Cross or another similar federal, state or local disaster relief agency or authority, to help the agency locate persons affected by the disaster.
- Directory Information – Except when you object, the hospitals may share your location and general condition with persons who request information about you by name, and may share all of your directory information with members of the clergy.
When is your written authorization required?
Except for the types of situations listed above, we must obtain your written permission, known as an authorization, for any other types of releases of your health information. An authorization is required for the sale of your health information or for marketing purposes and for most uses and disclosures of psychotherapy notes. If you provide us authorization to use or release health information about you, you may cancel (revoke) that authorization in writing at any time. Any authorization you sign may be cancelled (revoked) by following the instructions described on the authorization form. For questions, contact the Privacy Office.
Other uses and disclosures of your health information not described in this Notice may be made only with your written authorization, and you have the right to cancel (revoke) your authorization.
What are your rights regarding your health information?
UT Southwestern wants you to know your rights regarding your health information.
- Right to Receive this Notice of Privacy Practices – You have the right to receive a paper copy of this notice at any time. You may obtain a copy of the current notice in all clinical areas or by visiting the Privacy Office.
- Right to Request Confidential Communications – You have the right to ask that UT Southwestern communicate your health information to you in different ways or places. For example, you can ask that we only contact you by telephone at work, or that we only contact you by mail at home or at a post office box. We will do this whenever it is reasonably possible. You can make a request in the clinic or hospital, or contact the Privacy Office.
- Right to Request Restrictions – You have the right to request restrictions or limitations on how your health information is used or released. We have the right to deny your request.
Paid In Full – You may request that we not disclose your health information to your health plan if: you have paid for a health care item or service in full and paid for the item or service out of your own pocket. We must honor your request to restrict your health information from being disclosed to your health plan for purposes of payment or health care operations unless the disclosure is required by law. You may obtain information about how to ask for a restriction on the use or release of your health information to your health plan by contacting the Privacy Office.
- Right to Access – With a few exceptions, you have the right to review and receive a copy of your health information and claims records. You (your personal representative or a person chosen by you) also have a right to request a copy of your completed test results. Some of the exceptions include:
- Psychotherapy notes;
- Information gathered for court proceedings; and
- Any information your provider feels would cause you to commit serious harm to yourself or to others.
To receive a copy of your record or completed test results, or to direct your health information or completed test results to be sent to another person chosen by you, call 214-645-3030. This office will provide you with the necessary forms and assistance. You may request and receive an electronic copy of your electronic record or completed test results. We may charge you a cost-based fee, which may include copying and/or mailing your health record or completed test results to you. If you are denied access to your health record or to your completed test results for any reason, UT Southwestern will tell you the reasons in writing. We will also give you information about how you can file an appeal if you are not satisfied with our decision.
- Right to Amend – You have the right to ask that UT Southwestern’s information in your health record be changed if it is not correct or complete. You must provide the reason why you are asking for a change. You may request a change by sending a request in writing to the Privacy Office. This office will provide you with the necessary forms and assistance. We may deny your request if:
- We did not create the information;
- We do not keep the information;
- You are not allowed to see and copy the information; or
- The information is already correct and complete.
- Right to a Record of Releases (Accounting) –You have the right to ask for a list of releases of your health information by sending a request in writing to the Privacy Office. Your request may not include dates earlier than the six years prior to the date of your request. If you request a record of releases more than once per year, UT Southwestern may charge a fee for providing the list. The list will contain only information that is required by law. This list will not include releases for treatment, payment, health care operations or releases that you have authorized.
- Right to be Notified of Disclosure of Unsecured Health Information – You have the right to be notified following a breach of your unsecured health information.
Additional rights under European Union law
UT Southwestern intends to comply with all EU law concerning personal data and collects data for the lawful purpose of providing health care services. You may have additional rights under EU law. For additional information or for actions to exercise these additional rights under EU law, please contact the Privacy Office.
What can you do if you have a complaint?
If you believe that your privacy rights have been violated, you may file a complaint with UT Southwestern or with the Secretary of Health and Human Services. To receive help in filing a complaint with UT Southwestern, you may contact the Privacy Office at the address at the end of this notice. You will not be denied treatment or penalized in any way if you file a complaint.
Privacy Officer Contact Information
UT Southwestern Medical Center
5323 Harry Hines Blvd.
Dallas, Texas 75390-8851