NOTICE OF PRIVACY PRACTICES 
Medical Records Release of Information Form
This 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.
The United States Department of Health and Human Services created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). For the purpose of complying with HIPAA, Texas Orthopedics, Sports and Rehabilitation Associates and Texas Orthopedics Surgery Center are working together as a single affiliated covered entity (ACE) to protect your privacy. The ACE is part of a larger group, known as an organized healthcare arrangement (OHCA), that works to protect your privacy by coordinating efforts with other health care providers who may provide care to you in our facilities. These providers include Austin Radiological Association, Capitol Anesthesiology Association, and Austin Anesthesiology Group, LLP. This privacy notice applies to any of the entities or providers included in the OHCA that provide care to you in our facilities.
Uses and Disclosures
Treatment, Payment, Health Care Operations
Treatment
We are permitted to use and disclose your medical information to those involved in your treatment. For example, we may request that your primary care physician share your medical information with us and we may share information about your particular condition so that he or she can appropriately treat you for other medical conditions, if any, and/or assist us in obtaining insurance referrals as may be required by your health plan. Your care may also require the involvement of other specialists, for example, a pain management physician or pathologist. When we refer you to a specialist, we will share some or all of your medical information with that physician to facilitate the delivery of care.
Payment
We are permitted to use and disclose your medical information to bill and collect payment for the services provided to you. For example, submitting a claim form to your insurer in order to obtain payment for services provided to you. The form will contain medical information, such as a description of the medical service provided, that your insurer requires to approve payment to us. It may also be necessary to provide clinical documentation to your insurer for payment, for example, clinic office notes, operative or procedure notes and diagnostic studies.
Health Care Operations
We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this organization and ensure that quality care is delivered. For example, we seek the continual approval of the Joint Commission on Accreditation of Health Care Organizations (JCAHO) to ensure quality performance and delivery of patient care at Texas Orthopedics Surgery Center. Surveillance cameras are placed in a variety of locations within our facilities for safety and security purposes only.
Business Associates
Texas Orthopedics may disclose your medical information to third party business associates to perform certain activities of treatment, payment and operations on our behalf. We have written contracts with these associates that protect the privacy of medical information as required by HIPAA. Examples include transcription services and after hours answering services.
Disclosures That Can Be Made Without Your Authorization
There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object.
Public Health, Abuse or Neglect, and Health Oversight
We may disclose your medical information for public health activities. Public health activities are mandated by federal, state, or local government for the collection of information about disease, vital statistics (like births and death), or injury by a public health authority. We may disclose medical information, if authorized by law, to a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may disclose your medical information to report reactions to medications, problems with products or medical devices, or to notify you in the event of a recall of any product or device.
We may also disclose medical information to a public agency authorized to receive reports of child abuse or neglect. Texas law requires physicians to report child abuse or neglect. Regulations also permit the disclosure of information to report abuse or neglect of elders or the disabled.
We may disclose your medical information to a health oversight agency for those activities authorized by law. Examples of these activities are audits, investigations, licensure applications and inspections which are all government activities undertaken to monitor the health care delivery system and compliance with other laws, such as civil rights laws.
Legal Proceedings and Law Enforcement
We may disclose your medical information in the course of judicial or administrative proceedings in response to an order of the court (or the administrative decision-maker) or other appropriate legal process. Certain requirements must be met before the information is disclosed.
If asked by a law enforcement official, we may disclose your medical information under limited circumstances provided that the information:
Is released pursuant to legal process, such as a warrant or subpoena; Is released to locate a fugitive, missing person, or suspect. Pertains to a victim of crime and you are incapacitated; Pertains to a person who has died under circumstances that may be related to criminal conduct; Is released because of a crime that has occurred on these premises; or We believe the disclosure is necessary to prevent or lessen an imminent threat to the health or safety of a person. Workers’ Compensation
We may disclose your medical information as required by state and federal law regarding a work-related injury.
Inmates
If you are an inmate or under the custody of law enforcement, we may release your medical information to the correctional institution or law enforcement official. This release is permitted to allow the institution to provide you with medical care, to protect your health or the health and safety of others, or for the safety and security of the institution.
Military, National Security and Intelligence Activities, Protection of the President
We may disclose your medical information for specialized governmental functions such as separation or discharge from military service, requests as necessary by appropriate military command officers (if you are in the military), authorized national security and intelligence activities, as well as authorized activities for the provision of protective services for the President of the United States, other authorized government officials, or foreign heads of state.
Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors
When a research project and its privacy protections have been approved by an Institutional Review Board or privacy board, we may release medical information to researchers for research purposes. We may release medical information to organ procurement organizations for the purpose of facilitating organ, eye, or tissue donation if you are a donor. Also, we may release your medical information to a coroner or medical examiner to identify a deceased or a cause of death. Further, we may release your medical information to a funeral director where such a disclosure is necessary for the director to carry out his duties.
Disclosures Requiring an Opportunity to Agree or Object
We honor the important role that families, friends and other loved ones play in supporting our patient’s health care and treatment. At the same time, we are committed to protecting our patient’s privacy as well as complying with both state and federal law. Accordingly, disclosures to other people, even family, must remain a decision that rests with the patient.
If you bring a family member or other person to an appointment with you in our facility, they will be exposed to your personal health information. It is our practice to allow these individuals to accompany you to your appointment unless you otherwise object. Should you wish to visit the doctor alone, your visitor will be asked to wait in the lobby.
If you would like us to share your medical information with a member of your family, either by copies of your medical records or verbally, we will require a written authorization to do so. You may revoke this authorization at any time in writing.
Other Uses and Disclosures
Other uses and disclosures will be made only with your written authorization. You may revoke this authorization at any time in writing.
Certain Uses and Disclosures
Appointment Reminders, Treatment Alternatives, and Other Health-related Benefits It is our common practice to provide appointment reminders via telephone. We may leave a message on a home answering machine, business or mobile voice mail or leave a message with an individual answering your home telephone to remind you of your appointment. It is our standard procedure to send appointment reminder postcards for missed appointments. We may also mail information to you about treatment alternatives, or other health-related benefits and services that may be of interest to you. You have the right to request that we modify the above procedures for you. These requests should be made in writing to the contact person listed below. We will make our best effort to accommodate your request.
Your Rights Under Federal Privacy Regulations
The HIPAA regulations create several privileges that patients may exercise. We will not retaliate against a patient that exercises their rights.
Requested Restrictions
You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment, or healthcare operations. We may not be able to agree to this restriction in all cases.
To request a restriction, submit the following in writing: (a) The information to be restricted, (b) what kind of restriction you are requesting (i.e. on the use of information, disclosure of information or both), and (c) to whom the limits apply. Please send the request to the address and contact person listed below.
Receiving Confidential Communications by Alternative Means
You may request that we send communications of protected health information by alternative means or to an alternative location. This request must be made in writing to the contact person listed below. We are required to accommodate only reasonable requests. Please specify in your correspondence exactly how you want us to communicate with you and, if you are directing us to send it to a particular place, the contact/address information.
Inspection and Copies of Protected Health Information
You may inspect and/or copy health information that is within your medical records. Texas law requires that requests for copies be made in writing and we ask that requests for inspection of your health information also be made in writing. Please send your request to the contact person listed below.
You may not be entitled to review and access portions of the record including:
Psychotherapy notes contained in our records may not be reviewed or copied. Information compiled in anticipation, or for use in, a civil, criminal or administrative action or proceeding. Portions of the record are denied access under other federal or state law. The records involve medical research. The records were obtained from someone other than a health care provider under a promise of confidentiality, and access would likely reveal the source of the information. We can also refuse to provide access to or copies of some information if the physician has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the individual or other person. In this event, you will have an opportunity to request a review of our decision by another licensed health care provider who was not involved in the prior decision to deny access. We will then provide or deny access in accordance with the determination of the reviewing provider.
HIPAA permits us to charge a reasonable cost based fee. The Texas State Board of Medical Examiners (TSBME) has set limits on fees for copies of medical records. If a summary or explanation of the medical record is desired, there will be a charge for preparation of the narrative.
Texas law requires that we provide copies or a narrative within 15 days of your request and payment. We will inform you of when the records are ready or if we believe access should be limited. If we deny access, we will inform you in writing.
Amendment of Medical Information
You may request an amendment of information in your medical record. Any such request must be made in writing to the contact person listed below. For your convenience, we have created a form with all of the pertinent information needed to evaluate your request for amendment. We will respond within 60 days of your request. We may refuse to allow an amendment if the information:
Was created outside this practice Pertains to information that is not part of our medical record. Is not available for inspection because of an appropriate denial as described above. If the information is accurate and complete. If we refuse to allow an amendment we will inform you in writing. If we approve the amendment, we will inform you in writing, allow the amendment to be made and provide you with a copy of the amended record. If that particular record was disclosed to another party we will provide that party with a copy of the amended record. Even if we refuse to allow an amendment you are permitted to include a patient statement about the information at issue in your medical record.
Accounting of Certain Disclosures
The HIPAA privacy regulations permit you to request, and us to provide, an accounting of disclosures that are other than for treatment, payment, health care operations, circumstances required by state or federal law or made via an authorization signed by you or your personal representative. Please submit any request for an accounting to the contact person listed below.
Right to a Copy of Privacy Notice
You have the right to receive this notice electronically via our website at www.txortho.com or to receive a paper copy of the notice upon your request. Copies of the notice are available at the front desk in each of our offices.
Texas Orthopedics’ Duties
Our Promise to You
We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protected health information, and to abide by the terms of the notice of privacy practices in effect.
We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in each lobby.
Complaints
If you are concerned that your privacy rights have been violated, you may contact the contact person listed below. You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United States Department of Health and Human Services is:
Region VI, Office for Civil Rights
U.S. Department of Health and Human Services
1301 Young Street, Suite 1169
Dallas, TX 75202
Contact Persons for Questions/Complaints/Requests
Quarry Lake: Richard Hicks 4700 Seton Center Pkwy, Ste 200 Austin, TX 78759 512-439-1000
34th Street: Dora Mancias 630 West 34th St., Ste 304 Austin, TX 78705 512-439-1002
Westlake: Dolores DeLaTorre 5656 Bee Caves Rd., Ste G201 Austin, TX 78746 512-439-1005
Cedar Park: Anissa Salazar 1401 Medical Parkway B, Ste 120 Cedar Park, TX 78613 512-439-1009
Round Rock: Anissa Salazar 15808 RR 620 North, Ste. 100 Round Rock, TX 78717 512-439-1004
Marble Falls: Richard Hicks 1701 US Hwy 281 Marble Falls, TX 78654 512-439-1000
Surgery Center: Yvonne Powers 4700 Seton Center Pkwy, Ste 100 Austin, TX 78759512-439-1000
Effective Date
This notice is effective July 13, 2009.
