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This notice describes how medical information about you may be used and disclosed as well as how you can access this information. If you have any questions about this notice, please contact our Privacy Officer at 281.358.1495.


Our Pledge Regarding Protected Mental Health Information

This notice describes our healthcare system's practices and that of all persons employed or contracted by Kingwood Pines.

We understand that your mental health information is personal and confidential, and we pledge that we will protect this information about you. We will create a record of the care and services you receive at Kingwood Pines in order to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the healthcare system.


We are required by law to:

  • make sure that medical information that identifies you is kept private;
  • give you this notice of our legal duties and privacy practices with respect to your protected health information; and
  • follow the terms of this notice.

How We May Use & Disclose Medical Information About You

Due to the confidentiality of your mental health and/or chemical dependency information, Kingwood Pines will only disclose information regarding your treatment upon receiving a proper authorization from you. Exceptions include when the information is needed for treatment, payment, or healthcare operations as well as when required by federal, state, or local law.

For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, healthcare students, clergy, or others who are involved in your care. Different departments of the healthcare system may share medical information about you in order to coordinate the different services you need. We may disclose information to persons outside the hospital involved in continuing your care (i.e., assisting you in scheduling follow-up appointments) so long as you have given us authorization to do so.


For Payment: We may use and disclose medical information about you so that the treatment and services provided to you by the healthcare system may be billed. Payment may be collected from you, and insurance company, or a third party. We may need to give your health plan information about your treatment in order for your health plan to pay us or to reimburse you. We may also tell your health plan about treatment you are going to receive to obtain prior approval or to determine if your plan will cover the treatment.


For Healthcare Operations: We may use and disclose medical information about you for healthcare system operations. Information used in this sense may be to analyze the services we provide, to evaluate staff performance, and for educational purposes.


Fund-raising Activities. The hospital, or a foundation related to the hospital, may use information about you in an effort to raise money for the hospital and its operations. This information would include your name, address, phone number, and the dates you received treatment or services. If you do not want the system to contact you for fund-raising efforts, you must notify our Privacy Officer in writing.


Special Situations

Research and Health-Related Alternatives: Under certain circumstances, we may use and disclose medical information about you for research purposes, notification of treatment alternatives, and/or health-related benefits and services. We will remove information that identifies you from this set of medical information in order to protect your identity. We will ask for your specific permission if the situation would require access to your name, address or other information that reveals who you are.


Organ and Tissue Donation: If you are an organ donor, we may release medical information as necessary to facilitate organ or tissue donation and transplantation.


Workers' Compensation: We may release medical information about you to for workers' compensation or similar programs upon receipt of a proper written authorization from you or as required by law.


Reporting Public Health Risks: We may use and disclose medical information about you to agencies when required by law to prevent a serious threat to the health and safety of you or another person. Examples of such situations include:

  • to prevent or control disease, injury or disability,
  • to report births and deaths;
  • to report abuse and/or neglect;
  • to report reactions to medications or problems with products.

Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.


Coroners and Medical Examiners: We may release medical information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death.


Legal Disclosures: If you are involved in a lawsuit or a legal dispute, we may disclose medical information about you in response to a court or administrative order which has been signed by a judge or such person given equal authority under the law.


Government/Law Enforcement Agencies: We will disclose medical information about you when required to do so by federal, state, or local law.



  • Members of the armed forces - we may release medical information about you as required by military command authorities.
  • Foreign military personnel - we may release medical information about you to the appropriate foreign military authority.

We may release medical information about you:

  • If asked to do so by a law enforcement official in response to a court order which has been signed by a judge and in certain cases involving emergencies, criminal activities, missing persons, and death.
  • When it is requested by authorized federal officials for intelligence, counterintelligence, and other national security activities authorize by law including, but not limited to, the protection of the President, other authorized persons, or foreign heads of state, or conduct special.
  • To the correctional institution or law enforcement official if you are an inmate of a correctional institution or are under the custody of a law-enforcement official.

Other Uses of Medical Information:Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission.


Changes to This Notice: We reserve the right to change this notice. We reserve the right to make the revised notice effective for medical information we already have about you as well as any information we receive in the future. The effective date of the notice will be located on the first page in the top right-hand corner.


You have the following rights regarding the medical information we maintain about you:

  • The right to review your records or receive a copy of your records at any time. You will be asked to complete a written authorization in order to facilitate your request. We do have the right to deny your request under certain circumstances.
  • The right to make a written request to amend the information contained within your medical record if you feel the information is incorrect or incomplete. The request must provide a reason that supports your request. We do have the right to deny your request for any of the following:
    • Failure to make the request in writing;
    • Failure to include a reason to support the request;
    • If the information was not created by us and the entity that created is availableto make the amendment;
    • If the request is to amend information not:
      • part of the medical records kept by or for the healthcare system, or
      • part of the record you would be permitted to inspect and copy.
    • If the information you are requesting to amend is accurate and complete.
    • The right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
    • The right to restrict certain parties from receiving your medical information; however, the healthcare system is not required to agree to the restriction.
    • The right to receive confidential communication regarding your protected health information.
    • The right to revoke any authorization to release medical information about you. The revocation must be in writing and will not include any information the healthcare system disclosed prior to receiving the written revocation.
    • The right to receive a copy of this privacy notice at any time by requesting a copy from any of our system personnel.


If you believe your privacy rights have been violated, you may submit your complaint in writing to the Privacy Officer at the following address: 2001 Ladbrook Dr., Kingwood, TX 77339. If we cannot resolve your concern, you also have the right to file a written complaint with the Secretary of the Department of Health and Human Services. The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.


Quality of Care / Safety Concerns

If you have a patient safety or quality of care concern you have the right to contact Joint Commission on Accreditation of Healthcare Organizations either by phone, sending a written letter, or visiting their website. The information is below for your easy reference:


One Renaissance Boulevard
Oakbrook Terrace, IL 60181
1-630-792-5800 / 1-800-994-6610

© Cypress Creek Hospital
17750 Cali Drive, Houston, Texas 77090
Physicians are on the medical staff of Cypress Creek Hospital, but, with limited exceptions, are independent practitioners who are not employees or agents of Cypress Creek Hospital. The facility shall not be liable for actions or treatments provided by physicians.
Model representations of real patients are shown. Actual patients cannot be divulged due to HIPAA regulations.