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
