Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Who will follow this notice

This notice describes Cook Children’s practices and those of:

Any health care professional authorized to enter information into your medical record;
Any volunteer we allow to help you while you are in our care; and
All Cook Children’s employees, staff and other personnel.

The following entities within Cook Children’s Health Care System will follow these practices:

W.I. Cook Foundation Inc. dba Cook Children’s Health Foundation;
Cook Children’s Medical Center;
Cook Children’s Medical Center - Prosper;
Cook Children’s Health Care System;
Cook Children’s Physician Network;
Cook Children’s Surgery Center LLC;
Cook Children’s Pediatric Surgery Center;
Cook Children’s Home Health; and
Child Study Center

These entities, sites and locations follow the terms of this notice and may share protected health information with each
other for treatment, payment or operational purposes described in this notice.

The term “you” in this notice represents either you or your child.

Your rights

When it comes to your health information, you have certain rights. This section explains your rights and some of
our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information or have it sent to another person you designate. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information that you think is incorrect or incomplete. Ask us how to do this.
We are allowed to deny a request but will provide you the reason in writing within 60 days of the request.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will approve all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment or our operations. In most cases, we are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we've shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with and why.
We will include all the disclosures except for those about treatment, payment, health care operations and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the contact information on the back page.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, DC 20201, calling 1-877-696-6775 or visiting www.hhs.gov/hipaa/filing-a-complaint.
We will not retaliate against you for filing a complaint.

Your choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for
how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will
follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends or others involved in your care.
Share information in a disaster relief situation.
Include your information in a hospital directory.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We also may share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information, unless you give us written permission:

Marketing purposes.
Sale of your information.
Most sharing of psychotherapy notes.

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our uses and disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

We may use third party business associates to perform these functions. To safeguard your protected health information, Cook Children's has agreements with these third parties that require them to appropriately protect your information.

How else can we use or share your health information? We are allowed or required to share your information in other
ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many
conditions in the law before we can share your information for these purposes. For more information, see:
hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease.
Helping with product recalls.
Reporting adverse reactions to medications.
Reporting suspected abuse, neglect or domestic violence.
Preventing or reducing a serious threat to anyone's health or safety.

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law, or others who request it if sharing is required by the rules prohibiting information blocking.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner or funeral director when an individual dies.

Address workers' compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers' compensation claims.
For law enforcement purposes or with a law enforcement official.
With health oversight agencies for activities authorized by law.
For special government functions such as military, national security and presidential protective services.

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order or in response to a subpoena.

Our responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have comprised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information, see: https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the terms of this notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office and on our website.

Language assistance services

ATTENTION: If you speak English, free language assistance services are available to you. Appropriate auxiliary aids and services to provide information in accessible formats are also available free of charge. Call 1-682-885-4000 or speak to your provider.

لعربية (Arabic)

تنبيه: إذا كنت تتحدث اللغة العربية، فستكون خدمات المساعدة اللغوية المجانية متاحة لك. وتتوفر أيضًا مساعدات وخدمات إضافية ملائمة لتوفير المعلومات بتنسيقات يمكن الوصول إليها مجانًا. اتصل على 4000-885-682-1 أو تَحدَّث إلى موفر الخدمة الخاص بك..

繁體中文 (Chinese)

注意：如果您讲简体中文，我们可为您提供免费的语言协助服务。还免费提供适当的辅助工具和服务，以无障碍格式提供信息。请致电 1-682-885-4000 或与您的服务提供商联系。

Français (French)

À L'ATTENTION DE : Si vous parlez français, une aide linguistique gratuite est à votre disposition. Des aides auxiliaires et des services appropriés qui donnent des informations dans des formats accessibles sont également disponibles gratuitement. Appelez le 1-682-885-4000 ou parlez-en à votre prestataire.

Deutsch (German)

BITTE BEACHTEN SIE: Für den Fall, dass Sie Deutsch bevorzugen, stehen Ihnen kostenlos unterstützende Sprachdienste zur Verfügung. Dasselbe gilt für besondere Hilfsmittel und Hilfsdienste zur Bereitstellung von Informationen in zugänglichen Formaten. Bitte wählen Sie die 1-682-885-4000 oder wenden Sie sich an Ihren Gesundheitsdienstleister.

ગુજરાતી (Gujarati)

ધ્યાન આપો: તમે ગુજરાતી બોલતા હો, તો તમને ભાષાકીય સહાયતા માટે નિઃશુલ્ક સેવાઓ ઉપલબ્ધ છે. સુલભ ફૉર્મેટમાં માહિતી પ્રદાન કરવા માટે ઉચિત પૂરક સહાય અને સેવાઓ પણ નિઃશુલ્ક ઉપલબ્ધ છે. 1-682-885-4000 પર કૉલ કરો અથવા તમારા પ્રદાતા સાથે વાત કરો.

हिंदी (Hindi)

ध्यान दें: अगर आप हिंदी भाषीे हैं, तो आपके लिए मुफ़्त भाषा सहायता सेवाएं उपलब्ध हैं। सुलभ फ़ॉर्मेट में जानकारी उपलब्ध कराने के लिए उपयुक्त सहायक साधन और सेवाएं भी मुफ़्त में उपलब्ध हैं। 1-682-885-4000 पर कॉल करें या अपने प्रोवाइडर से बात करें।

日本語 (Japanese)

注意：日本語を話される場合は、無料の言語アシスタンスサービスがご利用になれます。アクセスできる形式で情報を提供するための適切な補助器具やサービスも無料でご利用になれます。電話（1-682-885-4000）またはプロバイダーにご相談ください。

한국어 (Korean)

주의: 한국어를 사용하는 경우 무료 언어 지원 서비스를 이용할 수 있습니다. 접근 가능한 형식으로 정보를 제공하기 위한 적절한 보조 도구와 서비스도 무료로 제공됩니다. 1-682-885-4000으로 전화하거나 서비스 제공업체에 문의하세요.

ພາສາລາວ (Laotian)

ແຈ້ງໃຫ້ຊາບ: ຖ້າທ່ານເວົ້າພາສາລາວ, ການຊ່ວຍເຫຼືອດ້ານພາສາໂດຍບໍ່ມີຄ່າໃຊ້ຈ່າຍ ມີໃຫ້ທ່ານ ອຸປະກອນຊ່ວຍແລະບໍລິການທີ່ເໝາະສົມເພື່ອໃຫ້ຂໍ້ມູນໃນຮູບແບບທີ່ເຂົ້າໃຈງ່າຍ ກໍມີໃຫ້ໂດຍບໍ່ມີຄ່າໃຊ້ຈ່າຍເຊັ່ນກັນ ກະລຸນາໂທ 1-682-885-4000 ຫຼື ໃຫ້ສົນທະນາກັບຜູ້ໃຫ້ບໍລິການຂອງທ່ານ

فارسی (Persian)

توجه اگر به زبان فارسی صحبت می کنید، خدمات رایگان کمک زبانی برای شما فراهم می باشد. ابزارها و خدمات کمکی مناسب برای ارائه اطلاعات در قالب های قابل دسترس نیز به صورت رایگان در دسترس شما می باشند. با شماره 1-682-885-4000 تماس بگیرید یا با ارائه دهنده ی خدمات خود صحبت نمایید.

Русский (Russian)

ВНИМАНИЕ: Если вы говорите по-русски, вам доступны бесплатные услуги языковой помощи. Соответствующие вспомогательные средства и услуги для предоставления информации в доступных форматах также бесплатны. Позвоните 1–682–885–4000 или обсудите тему с поставщиком услуг.

Español (Spanish)

ATENCIÓN: si habla español, contamos con servicios gratuitos de asistencia lingüística para usted. Los servicios y las ayudas auxiliares apropiados para proporcionar información en formatos accesibles también están disponibles libre de costo. Llame al 1-682-885-4000 o hable con el profesional de salud que lo atiende.

Tagalog (Tagalog)

PAUNAWA: Kung nagsasalita ka ng Tagalog, mayroon kang magagamit na mga libreng serbisyo ng tulong sa wika. Mayroon ding mga naaangkop na auxiliary na tulong at serbisyo na magbibigay ng impormasyon sa mga accessible na format na magagamit nang libre. Tumawag sa 1-682-885-4000 o makipag-usap sa provider mo.

اُردُو (Urdu)

توجہ فرمائیں: اگر آپ اردو بولتے ہیں، تو زبانی معاونت کی مفت خدمات آپ کے لیے دستیاب ہیں۔ معلومات فراہم کرنے کے لیے قابل حصول فارمیٹس میں موزوں اضافی امداد اور خدمات بھی مفت میں دستیاب ہیں۔ 1-682-885-4000 پر کال کریں یا اپنے فراہم کنندہ سے بات کریں۔

Tiếng Việt (Vietnamese)

NƠI NHẬN: Nếu quý vị nói Tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho quý vị. Các dịch vụ và hỗ trợ bổ sung thích hợp để cung cấp thông tin ở các định dạng dễ tiếp cận cũng được cung cấp miễn phí. Gọi 1-682-885-4000 hoặc trao đổi với nhà cung cấp dịch vụ của quý vị.

Contact information

Cook Children's
801 7th Ave.
Fort Worth, TX 76104

Website: cookchildrens.org

Privacy Officer
Phone: 682-885-7822
Email: privacyofficer@cookchildrens.org