The only information that FTUSA obtains about individual visitors to its website is that supplied voluntarily by visitors. By accessing the website, you grant FTUSA the right to transmit, monitor, retrieve, store and use your information in connection with the operation of the website. For example, we use the personal information you provide to us when you send us e-mails in order to reply to your e-mail. Please note that e-mail is not an entirely secure medium, and you should take appropriate precautions when contacting us to send personal or confidential information.
FTUSA goal is to forge a long-term partnership with you, and we value and appreciate the trust that accompanies your online donation. If you donate online, FTUSA will not sell, rent or trade the information you supply in connection with the donation to a third party.
Effective date: November 10, 2014 Last update: June 29, 2016
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW CAREFULLY.
If you have any questions about this Notice, please contact CRIT-USA’s Privacy Officer at 210-257-6260 or firstname.lastname@example.org.
This Notice of Privacy Practices applies to the following organizations: CRIT-USA, its professional staff, employees, volunteers, and the medical staff of Professionals Associated for Children’s Benefits (PACB).
We understand that medical information about you and your health is personal and we are committed to protecting this information. When you receive care from CRIT-USA, a record of the care and services you receive is made. Typically, this record contains your treatment plan, history and physical, test results, and billing record. This record serves as a:
This notice tells you the ways we may use and disclose your Protected Health Information (referred to herein as “medical information”). It also describes your rights and our obligations regarding the use and disclosure of medical information. Our Responsibilities CRIT-USA is required by law to:
2. Provide you with notice of our legal duties and privacy practices with respect to information we collect and maintain about you;
The methods in which we may use and disclose medical information about you. The following categories describe different ways we may use and disclose your medical information. The examples provided serve only as guidance and do not include every possible use or disclosure.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW CAREFULLY
If you have any questions about this Notice, please contact CRIT-USA’s Privacy Officer at 210-257-6260 or email@example.com
This Notice of Privacy Practices applies to the following organizations: CRIT-USA, its professional staff, employees, volunteers,
and the medical staff of Professionals Associated for Children’s Benefits (PACB), follow the privacy practices described in this Notice.
Psychotherapy notes about you may be used and disclosed without your written authorization in the following situations:
All other uses and disclosures of psychotherapy notes require your written authorization. You have the right to revoke such authorization in writing.
Your rights regarding your medical information. You have the following rights regarding medical information collected and maintained about you:
CRIT-USA may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by CRIT-USA will review your request and denial. The person conducting the review will not be the person who denied your request. CRIT-USA will comply with the outcome of the review.
We reserve the right to change our practices and to make the new provisions effective for all PHI we maintain. Should our information practices change, we will post the amended Notice of Privacy Practices in our office and on our website. You may request that a copy be provided to you by contacting the Privacy Officer.
If you believe your privacy rights have been violated, you may file a complaint with CRIT-USA or with the Office for Civil Rights, U.S. Department of Health and Human Services. To file a complaint with CRIT-USA, contact the Privacy Officer at 210-257-6260. Your complaint must be filed within 180 days of when you knew or should have known that the act occurred. The address for the Office of Civil Rights is:
Secretary of Health & Human Services Region VI, Office for Civil Rights U.S. Department of Health and Human Services 1301 Young Street, Suite 1169 Dallas, TX 75202. All complaints should be submitted in writing. You will NOT be penalized for filing a complaint.
Patient Name: ________________________
Date of Birth: ________________________
I acknowledge that I am the parent/legal guardian of above patient and that I have received a copy of this office’s Notice of Privacy Practices on his/her behalf and that I have been afforded the opportunity to ready the Notice of Privacy Practices and ask questions:
Parent/Legal Guardian Name: ________________________
Parent/Legal Guardian Signature: ________________________
Relationship to patient: ________________________
We are committed to taking precautions to secure your information. In order to prevent unauthorized access or disclosure, we have put in place safeguards to secure the information we collect online. We use encryption practices to help protect the integrity and privacy of the personal information you provide to us. As an added security precaution, all personal information is kept on servers with firewalls that meet or exceed industry standards to prevent intruders from gaining access. However, FTUSA cautions visitors to its websites that no network, including the Internet, is entirely secure. Accordingly, we cannot be responsible for loss, theft, misuse, alteration, corruption or unauthorized acquisition of personal information provided to our website, or for any damages resulting from such loss, corruption or unauthorized acquisition. By using this website, you understand and acknowledge that data and communications, including e-mail and other electronic communications, may be accessed by unauthorized third parties when communicated over the Internet.
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