Request Appointment

If you would like to learn more about ketamine infusion therapy and how it can help you, contact Active Ketamine Clinic in Houston today. Regardless of how innovative and cutting-edge a treatment is, it’s by no means the correct course of action for every patient. Treatment of any medical condition is only as good as the team that provides it. For your personalized consultation, get in touch with our compassionate and knowledgeable staff today.

Contact Us

Name(Required)
MM slash DD slash YYYY

Referring Clinician

Address

12250 Queenston Blvd., Ste. E,
Houston, TX 77095

Phone

281-201-4511

Hours

Mon–Fri: 7AM–4PM
Sat–Sun: Closed

HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used, disclosed, and safeguarded, and how you can obtain access to this information. Please review it carefully. For purposes of this notice, the use of the word “office” should be taken to mean Active Ketamine. In all cases where the words “you” or “patient” are used, it should be taken to mean “the patient or their parent/legal guardian”.

Active Ketamine has a legal duty to safeguard your protected health information (“PHI”) and keep it private. PHI constitutes information created or noted by this office that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or payment for such health care. This notice is required to explain when, why, and how your PHI would be used and/or disclosed by this office. Use of PHI is when information is shared, applied, utilized, examined, or analyzed within the office; disclosure of PHI is when information is released, transferred, given, or otherwise revealed to a third party outside of this office. With some exceptions, your PHI will not be used or disclosed more than is necessary to accomplish the purpose for which the use or disclosure is made. Following the privacy practices described in this notice is legally required. Any changes to these practices will apply to PHI already on file. Before any changes to policies are made, this notice may be modified and a new copy of it will be posted in the office and on the website. You may also request a copy of this notice from our office.

How your PHI will be used and disclosed. Your PHI may be used and disclosed for many different reasons. Some of the uses or disclosures will require your prior written authorization; however, others will not.

A. Uses and disclosures related to treatment, payment, or office health care operations do not require your prior written consent.
1. For treatment. Your health information may be used to give you medical treatment or services. Your PHI may be disclosed to pharmacists and their assistants, and other professionals involved in your care to put in place a treatment plan and to carry out that plan. For example, your PHI may be provided to clarify medication instructions with a pharmacy, obtain prior authorization for certain medications from insurance entities, or disclose health information to physicians who provide follow-up care to you.
2. For health care operations. Your PHI may be disclosed to facilitate the efficient and correct operation of this medical practice. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, conducting business or arranging for other related activities.
3. To obtain payment for treatment. Your PHI may be used and disclosed to bill and/or collect payment for the treatment and services provided to you.
4. Minors. If you are an un-emancipated minor (i.e., not legally authorized to act as adult) under Texas law, there may be circumstances in which we disclose health information about you to a parent, guardian, or other person acting in loco parentis, in accordance with our legal and ethical responsibilities.
5. Parents. If you are a parent of an un-emancipated minor, and are acting as the minor’s personal representative, we may disclose health information about your child to you in certain circumstances. If we are legally required to obtain your consent as your child’s personal representative in order for your child to receive care from us, we may disclose health information about your child to you. In some circumstances, we may not disclose health information about an un-emancipated minor to you. If your child is legally authorized to consent for treatment, we may not disclose health information about your child to you without your child’s written permission.
6. Other disclosures. Your consent is not required if you need emergency treatment. In the event that this office tries to get your consent but you are unable to communicate (e.g., unconscious), but it is reasonable to assume that you would consent to such treatment if you could, your PHI may be disclosed.
7. Required by law. This office may make a disclosure to the appropriate officials when a law requires reporting information to government agencies, law enforcement personnel, and/or administrative proceedings.
8. Disclosure may be compelled by a party to a proceeding before a court or an administrative agency pursuant to its lawful authority, or if a search warrant is lawfully issued to a law enforcement agency.
9. Health and safety codes and federal regulations. Disclosure may be compelled by the patient or the patient’s representative pursuant to Texas Health and Safety Codes or to corresponding federal statutes or regulations, such as the privacy rule that requires this notice.
10. To avoid harm. PHI may be provided to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person including yourself or the public. This includes when disclosure is necessary to prevent the threat of danger from occurring.
11. Child/elder abuse and neglect. Disclosure may be mandated by the Texas child abuse and neglect reporting law or the Texas elder/dependent adult abuse reporting laws.
12. Threat of violence. Disclosure may be compelled or permitted by the fact that you tell this office of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.
13. Public health. Disclosure may be permitted to public health officials, if required.
14. Health oversight activities. This office may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization.
15. Specific government functions. PHI may be disclosed as a matter of national security.
16. Worker’s compensation purposes. In certain circumstances, PHI may be provided in order to comply with workers’ compensation laws.
17. Appointment reminders and health related benefits/services. PHI may be used to provide appointment reminders.
18. If disclosure is otherwise specifically required by law.
B. In other situations not described above, your written authorization will be requested before using or disclosing any of your PHI. If you have signed an authorization to disclose your PHI, you may later revoke that authorization in writing to stop further disclosures.

Rights regarding your PHI.
A. The right to inspect and copy your PHI. You have the right to inspect and copy your PHI that is in our possession; however, you must request it in writing. You will receive a response within 15 days of our receipt of your written request. Under certain circumstances, your request may be denied. If so, you will receive the reason for denial in writing. You also have the right to have the denial reviewed. The charge for copying PHI is allowed by state law.
B. You have the right to ask that use and disclosure of your PHI be limited, but this office is not legally bound to agree. If your request is agreed to, those limits will be put in writing and abided by except in emergency situations. You do not have the right to limit the uses and disclosures that this office is legally required or permitted to make.
C. You have the right to choose how your PHI is sent to you. It is your right to ask that your PHI be sent to you at an alternate address. This office may agree to your request providing that the PHI can be rendered in the format you requested without undue inconvenience.
D. You have the right to amend your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request correction of the existing information or addition of the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of receipt of your request. Your request may be denied if the PHI is correct, complete, forbidden to be disclosed, not part of the records, or written by someone other than this office. Denials will be provided in writing. If approved, the change(s) will be made to your PHI.

If, in your opinion, your privacy rights have been violated, or if you object to a decision made about access to your PHI, you are entitled to file a complaint with Active Ketamine at 12250 Queenston Blvd, Suite E Houston, TX 77095, by calling (281) 201-4511, or by sending a written complaint to the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

Effective Date: 7/1/2022