Forms and Policies

• Authorization To Release Health Information - Once completed, this form enables UT Health Austin to share your medical record with another provider, or healthcare entity.
• Autorización para divulgar información de la salud - Una vez completado, este formulario permite a UT Health Austin compartir su expediente médico con otro proveedor o entidad de atención médica.
• Authorization to Receive Medical Records - Once completed, this form allows UT Health Austin to request your medical records from another provider or healthcare entity.
• Autorización para recibir registros médicos - Una vez completado, este formulario permite a UT Health Austin solicitar sus registros médicos de otro proveedor o entidad de atención médica.
• Authorization to Share Health Information - Once completed, the form allows your provider to discuss (verbally) your health information with another provider or healthcare entity.
• Autorización para Compartir Información de Salud - Una vez completado, el formulario permite a su proveedor discutir (verbalmente) su información de salud con otro proveedor o entidad de atención médica.

Notice Concerning Complaints

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

Aviso Sobre Las Quejas

Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

• UTHA Referral Form - Print and complete this form and fax to: 512-495-5680
• Comprehensive Memory Center - Due to a current waitlist of 4-6 months, at this time only internal referrals from UT Health Austin providers are being accepted.
• Livestrong Cancer Institutes and Surgical Oncology - Print and complete the UTHA Referral Form and fax to: 512-495-5709
• Authorization To Release Health Information- to expedite the referral process

Discrimination Is Against the Law

UT Health Austin complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. UT Health Austin does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

UT Health Austin provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)

UT Health Austin provides free language services to people whose primary language is not English, such as:

• Qualified interpreters
• Information written in other languages

If you need these services, please contact the Front Desk Personnel at any of our clinics.

If you believe that UT Health Austin has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Office
100 West Dean Keeton, Suite 3.212
Austin, Texas 78712, 512.471.1849
equity@utexas.edu

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Office of Inclusion and Equity is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html.

Download a copy of this policy in here (English and Spanish).

Approved: 11/3/2023

Approving Body: CEPAS

1. I. Policy

To set out rules for video and audio recording, and photographs by patients, families, visitors, or non-UT Health Austin (UTHA) staff using their own electronic devices during virtual, telehealth, or in-person visits, in both clinical and non-clinical areas (e.g. a waiting room) within the UTHA facilities.

This policy should be read with the UTHA Standards of Conduct for Patients, Families, and Visitors.

This policy can also be found within the new patient paperwork, and should be acknowledged and signed by each patient.

1. II. Scope

This policy applies to patients, families, visitors, and non-UTHA staff during both in-person and telehealth visits.

III. Procedures

• Patients and non-UTHA individuals may not use their own electronic devices (a) to take photographs or (b) to record video or audio conversations, about the patient’s own treatment, procedure, service, or medical records without first verbally requesting and obtaining verbal consent from the treating provider(s) or UTHA staff member(s) who will be included in the photographs or the recording. At any point, if they deem it necessary, the provider(s) or the UTHA staff member(s) may withdraw consent and request that the recording be deleted.
• Patients and non-UTHA individuals may not use their own electronic devices to take personal, non-clinical photographs, or to make video or audio recording in this setting.

Patients and non-UTHA individuals must respect the decision made by the treating provider(s) and the UTHA staff member(s) for consenting to or refusing to consent to being photographed or audio/visually recorded.

Download a copy of this policy here.

REFERENCE

UTHA Standards of Conduct for Patients, Families, and Visitors

Your Information. Your Rights. Our Responsibilities.

This Privacy 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.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical and billing records
• Ask us to correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this Notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services
• Raise funds

Our Uses and Disclosures

We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Improve Healthcare
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

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 and billing records

• You can ask to see or get an electronic or paper copy of your medical and billing records, and other health information we have about you, excluding psychotherapy notes. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 15 days of your request. We may charge a reasonable, cost-based fee.
• There may be times when we may not allow access to some records, or we may not be able to provide them in the way you want. We will inform you if this is the case.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we will tell you why in writing within 60 days.
  

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 say “yes” to 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. We are not required to agree to your request, and we may say “no” if it would affect your care or safety.
• 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 have shared information

• You can ask for a list (accounting) of the times we have 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, and health care operations, and certain other disclosures (such as any you asked us to make). We will 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 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 information on page 1.
• 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, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• 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 may also 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 first:

• Marketing purposes
• Sale of your information (we do not sell your information but are required to tell you your permission would be required first)
• 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.

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: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.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 may use or disclose your information for research purposes, but only as allowed by federal and state law. For example, we may access your information to design a research project or contact you about participating in a research activity. Before your information is used, however, most research is approved by an oversight body known as an Institutional Review Board (IRB) through a review process. We may also de-identify information about you or your care and use or disclose that information in research.

Improve Healthcare
We may collect and use your biometric data for purposes of improving healthcare (such as to develop patient care and treatment). We will not collect, retain, or disseminate the information without first asking your consent.

Your leftover blood or tissue may also be used, without being linked to you in any way, unless you opt out. Please let us know if you want to opt out.

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 are complying with federal privacy law.

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 compromised 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: 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 web site.

Effective Date

November, 2022

Please Contact

If you have any questions or concerns regarding this Notice, or want to exercise any of your rights under this Notice, please contact:

UTHealth Austin Privacy Officer
1501 Red River Street, Mail Code: Z0100
Austin, Texas 78712
uthealthaustinprivacy@austin.utexas.edu
512-495-5146

Information Sharing for Low Income Residents

We are part of the Community Care Collaborative Organized Health Care Arrangement (CCC OHCA) and this section applies to and describes the CCC OHCA. The CCC OHCA is an organized system of healthcare in which the following separate health care providers and plans participate in joint activities, such as quality improvement or payment activities:

• The Community Care Collaborative;
• Travis County Healthcare District d/b/a Central Health;
• The Seton Healthcare Family;
• Lone Star Circle of Care;
• People’s Community Clinic;
• Central Texas Community Health Centers d/b/a CommUnityCare;
• Austin Travis County Integral Care;
• El Buen Samaritano;
• Other physicians, community clinics, and health care providers providing treatment at the provider’s clinical locations; and certain participating health plans paying for healthcare services to low income individuals including, but not limited to, Sendero Health Plans.

If you meet certain income thresholds, based on financial information you have provided and our financial guidelines, we, and the other healthcare providers and plans who participate in the CCC OHCA, will share medical, billing and other health information about you with one another as may be necessary to carry out treatment, payment, and certain healthcare operations activities and as otherwise permitted by law and this Notice.

You are receiving this Notice because we believe your information will be shared through the CCC OHCA. More information about the CCC OHCA can be found here.

Download a copy of the Policy in English and Spanish.

At UT Health Austin, we strive to create a welcoming and respectful environment for our medical teams to deliver healthcare for you and your family. We encourage you to participate in your care process. Together, by working with you in a safe, respectful, and honest way we can provide the best care to you.

To ensure the best care experience for yourself, other patients, and your care teams, we respectfully request that you:

• Be considerate when using your cell phone or other electronic devices at UT Health Austin.
• Arrive on time for your appointment, ideally 10-15 minutes early. To respect the time and needs of patients who do arrive on time, any patient who is more than 30 minutes late for a scheduled appointment may not be seen and will likely be rescheduled.
• If you must cancel an appointment, we ask that you please do so as soon as possible, at least 24 hours in advance. We know that plans may change at the last minute, so even late notice is appreciated. Patients who miss more than 3 appointments may not be able to be rescheduled and will be notified.
• You must get permission before taking photographs/videos or voice recordings of anyone on your medical team.

To ensure a safe and respectful working environment, UT Health Austin finds certain behaviors to be unacceptable. These behaviors could lead to removal from the building and/or dismissal from the clinic.

Examples of unacceptable behaviors are:

• Disrupting another patient’s care or experience
• Bullying, intimidating, harassing staff or other patients
• Engaging in: profanity, assault, or infliction of bodily harm to self or others
• Engaging in or threatening violent behaviors either in person or in communications
• Making vulgar or derogatory remarks associated with race, ethnicity, sexual orientation, culture, language, age, disability, veteran status, or immigration status
• Requests, demands, or denial for clinical, learners, or another staff member (s) based on the above
• Damaging UTHA property or equipment
• Possessing illegal weapon(s) in prohibited areas
• Making requests that would constitute unethical or illegal behavior on the part of UTHA

UTHA has a zero-tolerance policy for aggressive behavior directed toward our providers, learners, and staff. If you personally experience or notice any alarming or unsafe behaviors, please report them to a member of our staff immediately.

Download a copy of this policy in English or Spanish.

Approved: 1/12/24

UT Health Austin (UTHA) and Dell Medical School (DMS) will reasonably accommodate patients and visitors with their service animals in compliance with federal[1] and state[2] laws, and this policy. A service animal means an animal (generally a dog) that has been specially trained or equipped to perform specific tasks directly related to the handler’s disability. Animals whose sole function is for emotional support, therapy, comfort, or companion are not considered service animals.

A service animal:

• Will be permitted to accompany its handler and enter the UTHA/DMS premises open to the public;
• May be permitted to accompany its handler and enter the areas not open to the public. Gaining admittance to such areas will be determined on a case by case review by the Executive Director of UTHA.
• Will not be permitted to accompany its handler and enter sterile areas, or clean rooms, where special precautions (such as wearing gloves, masks, and/or gowns) are required for the purposes of infection control. These areas include but are not limited to operating rooms, procedure rooms, recovery rooms, and other sterile areas.

A service animal may be denied admittance to or removed from the UTHA/DMS premises if the service animal:

• Exhibits aggressive behavior including, but not limited to, biting, excessive whining, barking, growling, scratching, or teeth baring;
• Is excessively noisy;
• Poses a direct risk to the safety and health of other service animals or people;
• Is not under the control of the handler;
• Is not well groomed or does not appear healthy, in which case our staff will ask for proof of vaccination or the dog’s health records prior to entering the premise.

It is the patient/handler’s responsibility to supervise, control, and care for the service animal, including the removal of the animal from the premises. UTHA/DMS will coordinate an alternative care for the animal at the handler’s expense if handler cannot perform such responsibilities.

Under the applicable laws, our staff will not ask you of the following:

• The qualifications of the service animal or the nature of the person’s disability;
• Require or request medical documentation, special identification card or training documentation for the service animal;
• Request that the service animal demonstrate its ability to perform the work or task.

However, in situations where the handler’s disability is not readily apparent, our staff may ask the following questions for clarification:

• Is the dog a service animal required because of a disability?
• What work or tasks has the dog been trained to perform?

The service animal that enters the premises must always be on a leash or harness.

If you have questions about bringing service animals onto the UTHA/DMS premises, contact the Executive Director of UT Health Austin and/or the Compliance Office.

Download a copy of this policy here.

[1] https://www.ada.gov/2010_regs.htm

[2] https://gov.texas.gov/organization/disabilities/assistance_animals#responsibilities