Privacy Statement

Effective 3/26/2013


If you have any questions, please contact the Privacy Office listed at the end of this Notice.

Who will follow this Notice?
Dubuis Health System, Inc. provides healthcare to our patients, residents and clients in partnership with physicians and other professionals and organizations. The information privacy practices in this Notice will be followed by:

  • Any healthcare professional who treats you at any of our locations;
  • All departments and units of our organization;
  • All employed Associates, staff or volunteers of our organization, including staff of our System office, associated hospitals and our host hospital, with which we may share information as permitted within our organized healthcare arrangement or as a single affiliated covered entity.
  • Any Business Associate, Business Associate sub-contractor or partner of Dubuis Health System, Inc. with whom we share health information.

Our pledge to you:

  • We understand that medical, billing and personal information is very important and we are committed to protecting the privacy of that information. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This Notice applies to all of the records of your care that we maintain, whether created by our Associates or your personal physician. Your personal physician may have different policies or Notices regarding the physician’s use and disclosure of medical, billing and personal information created in the physician’s office.
  • We will not sell your medical or personal information for direct or indirect payment without your authorization.

We are required by law:

  • To keep medical, billing and personal information about you private;
  • To give you this Notice of our legal duties and privacy practices with respect to your protected health information;
  • To notify you of an unauthorized disclosure of your unsecured medical, billing or personal information;
  • To follow the terms of the Notice currently in effect.

Changes to this Notice:
We may change our policies and privacy practices at any time. Changes will apply to your protected health information we already have, as well as new information obtained after the change occurs. When we make a significant change in our policies, we will change our Notice and post the new Notice prominently in waiting areas and on our website at You can receive a copy of the current Notice at any time. The effective date is listed just below the title. You will be offered a copy of the current Notice each time you register at our facility for treatment. You will also be asked to acknowledge your receipt of this Notice in writing.

How we may use and disclose your protected health information:
We may use and disclose medical, billing and personal information about you for:

  • Treatment (such as sending medical information about you to another provider of healthcare as part of a referral);
  • To obtain payment for care provided (such as sending billing information to your insurance company);  NOTE: if you pay out of pocket in full for the care or service provided, you have the right to ask us to restrict the disclosure of that information to your insurance company;
  • And to support our health care operations (such as comparing patient data to improve treatment methods).

We may use and disclose medical information about you without your authorization for:

  • Public health purposes;
  • Abuse or neglect reporting;
  • Health oversight audits or inspections;
  • Some research studies;
  • Funeral arrangements;
  • Organ donation;
  • Worker’s compensation purposes;
  • During emergencies;
  • When required by law, such as in response to a request from law enforcement officials in specific circumstances;
  • In response to valid judicial or administrative orders.

We may contact you without authorization for:

  • Appointment reminders;
  • To inform you about possible treatment options, alternatives, health-related benefits or services that may be of interest to you.

We may use certain demographic information without authorization:

  • Such as name, address, telephone number or e-mail address, date of birth, health insurance status, gender, dates of service, department of service information, treating physician information or outcome information to contact you for the purpose of fundraising. You have the right to opt-out of receiving future communications with each solicitation. Information on how to opt-out will be contained in each communication.
  • We may provide your name to an institutionally related foundation. The money raised will be used to expand and improve the programs and services we provide to the community. Information on how to opt-out will be contained in each communication.
  • Your decision to opt-out will have no impact on your treatment or payment for services at any Dubuis Health System, Inc. location.

If you are admitted as a patient:

  • You have the option of not being listed in the facility patient directory.
  • If you do chose to be listed in the directory, the following information will be listed and may be released to anyone who asks for you by name, except religious affiliation:
    • Your name
    • Your location in the facility
    • Your general condition (good, fair, guarded, critical, etc.)
  • Your religious affiliation may be disclosed to a facility employed clergy member, even if they do not ask for you by name.
  • We may disclose medical and billing information about you to a friend or family member who is involved in your medical care; or
  • To disaster relief authorities so that your family can be notified of your location and condition.

Other uses of your medical information:

  • Other than face-to-face conversations about services and treatment alternatives we will not use your protected information for marketing purposes without your authorization.
  • In any other situation not mentioned in this Notice, we will ask for your written authorization before using or disclosing your medical, billing or personal information.
  • If you choose to authorize the use or disclosure of your medical, billing or personal information, you can later revoke that authorization by notifying us in writing of your decision.

Your rights regarding your medical and billing information:

  • In most cases, patients have the right to look at or obtain a copy of their medical and billing information contained in the designated record set used to make decisions about their care.
  • You may request this information in a printed format or if the information is maintained electronically you may request an electronic copy of the information.
  • There may be a fee charged for the cost of supplies and labor for creating the paper or electronic copy.
  • If you believe that information in your designated record set is incorrect or that information is missing, you have the right to request that we correct the records. Your request must be submitted in writing and include the reason you are requesting the change. We can deny your request to change a record if the information you are requesting to be changed was:
    • not created by us,
    • is not part of the medical or billing information maintained by us, or
    • if we determine that the record is accurate.
  • You may appeal, in writing, a decision by us not to amend a record.
  • You have the right to a list of those instances when we have disclosed medical, billing and personal information about you, for reasons other than treatment, payment or healthcare operations or without your authorization. Your written request must identify a time period, which must be less than a six (6) year time period and after April 14, 2003. You may receive the list in a printed format or, if available, in an electronic format. There may be a cost associated with your request. You will be informed of the cost before any charges are incurred.
  • If you initially received this Notice electronically, you have the right to a paper copy.
  • You have the right to request that your medical and billing information be communicated to you in a confidential manner, such as sending mail to an address other than your home. You must notify us in writing of the specific manner or location for us to use to communicate with you.
  • You may request, in writing, that we not use or disclose your medical, billing or personal information for treatment, payment or healthcare operations to persons involved in your care except when specifically authorized by you, or when required by law, or in an emergency. We will consider your request but we are not legally required to honor the request.
  • You may pay for a service out of pocket in full and request that the encounter not be disclosed to your insurer.


  • If you are concerned that your privacy rights may have been violated or if you disagree with a decision made about access to your records, you may:
  • If you need help filing a complaint or have a question about the complaint or consent forms, you may e-mail OCR at or request help from the Privacy Office listed in this Notice.

Privacy Office Contact Information:
Debra Hebert-Myrick
919 Hidden Ridge
Irving, Texas 76038