Patient Privacy
NOTICE OF PRIVACY PRACTICES

Medical Records Release of Information Form

SUMMARY

The attached 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. This document is intended to serve as a summary of our privacy practices only.

The privacy notice applies to any of the providers that may provide care to you at Texas Orthopedics, Sports and Rehabilitation Associates or Texas Orthopedics Surgery Center including Texas Orthopedics, Austin Radiological Association, Capitol Anesthesiology Associates, Austin Anesthesiology, LLP.

Uses and Disclosures

Permitted without Authorization:

  • Treatment, Payment and Operations
  • Public Health, Abuse or Neglect, and Health Oversight
  • Legal Proceedings and Law Enforcement
  • Workers’ Compensation
  • Inmates
  • Military, Nat’l Security & Intelligence Activities, Protection of the President
  • Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors
  • Certain uses & disclosures including appointment reminders, treatment alternatives, and other health-related benefits
  • Require Authorization:

  • Disclosures to Friends or Family
  • Any other requested disclosure

    Your Rights Under Federal Privacy Regulations

  • Request restrictions or limit disclosures for treatment, payment or operations.
  • Receive confidential communications by alternative means
  • Inspection and Copies of Protected Health Information
  • Request amendment to your medical record
  • Accounting of Certain Disclosures
  • Right to a Copy of Privacy Notice

    Texas Orthopedics’ Duties

  • Protect the privacy of your medical information and to abide by the terms of the notice of privacy practices in effect.
  • Contacts for questions, complaints, amendments and accounting:

    Region VI, Office for Civil Rights

    U.S. Department of Health and Human Services

    1301 Young Street, Suite 1169

    Dallas, TX 75202

    Northwest Austin: Rose Marks 4700 Seton Center Pkwy, #200 Austin, TX 78759 512-439-1000

    Central Austin: Dora Mancias 630 W. 34th St., # 302 Austin, TX 78705 512-439-1002

    Westlake: Dolores Delatorre 5656 Bee Caves Rd, #G201 Austin, TX 78746 512-439-1005

    Round Rock: Anissa Salazar 2410 Round Rock Ave, #170 Round Rock, TX 78681 512-439-1004

    Cedar Park: Anissa Salazar 1401 Medical Pkwy B., #120 Cedar Park, TX 78613 512-439-1009

    Marble Falls: Rose Marks 1701 US Hwy 281 Marble Falls, TX 78654 512-439-1000

    Surgery Center: Sara Clyborne 4700 Seton Center Pkwy, #100 Austin, TX 78759 512-439-1000

    Effective Date: August 1, 2006

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