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Notice of Privacy Practices



Revised September 2013

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA)

We may use and disclose your PHI in the following ways:

The following categories describe the different ways in which we may use and disclose your PHI.

Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine test) and we may use the results to help us reach a diagnosis. We might use your PHI to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice - including, but not limited to, our doctors and nurses– may use or disclose your PHI to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.

Payment. Our practice may use and disclose your PHI to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice.

Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.

Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.

Health-related benefits and services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.

Release of information to family/friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a baby sitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.

Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

Use and disclosure of your PHI in certain special circumstances. The following categories describe unique scenarios in which we may use or disclose your identifiable health information.

Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information such as:

  • Maintaining vital records, such as births and deaths;
  • Reporting child abuse or neglect;
  • Preventing or controlling disease, injury or disability, and;
  • Notifying a person regarding potential exposure to a communicable disease.

Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions civil, administrative and criminal procedural or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general

Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have tried to inform you of the request or to obtain an order protecting the information the party has requested.

Law enforcement.  We may release PHI if asked to do so by a law enforcement official for certain purposes.

Deceased patient. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information for funeral directors to perform their jobs. Any PHI related to an individual who has been deceased 50 years or more, is no longer protected.

Organ and tissue donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation.

Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except, when an Internal Review Board or Privacy Board has approved the research project and its privacy protections.

Psychotherapy Notes. Most uses and disclosures of psychotherapy notes, uses and disclosures of protected health information for marketing purposes, and disclosures that constitute a sale of protected health information require authorization, as well as a statement that other uses and disclosures not described in the NPP will be made only with authorization from the individual.

Fundraising. Should you receive fundraising or marketing information, you have the right to "opt out" of receiving any fundraising or marketing communications.

Prohibition Against Sale. Our practice is prohibited from the sale of Protected Health Information without the express written authorization of the individual.

Our commitment to your privacy:

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practice that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time. Additionally, the practice is required to notify you of certain unauthorized access, acquisition or use of your medical information as required under the HIPPAA regulations.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location always, and you may request a copy of our most current Notice at any time.

If you have questions about this Notice, please contact:

Pain Relief and Rehabilitation
7504 San Jacinto Place
Plano, TX 75024
Call Us: 972-769-PAIN (7246)
Fax: 972-360-3977

Your rights regarding your PHI

You have the following rights regarding the PHI that we maintain about you:

Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a manner or at a certain location. For instance, you may ask that we contact you at home, rather than your work. To request a type of confidential communication, you must make a written request to, specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family, except in situations where you request that we restrict disclosure of your medical information to a health plan and the disclosure is for carrying out payment or health care operations and is not otherwise required by law to be disclosed and the medical information solely pertains to an item or service you, or another individual on your behalf, has paid the practice in full. We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. To request a restriction in our use or disclosure of your PHI, you must make your request in writing to

Your request must describe in a clear and concise fashion:

  • The information you want restricted;
  • Whether you are requesting to limit our practices’ use, disclosure, or    both; and
  • To whom you want the limits to apply.

Additionally, if you have paid out-of-pocket and in full for services, you have the right to request the restriction of certain disclosures to a health plan.

Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to .You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion; (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

Breach Notification.  Should an unsecured breach of your Protected Health Information occur, all affected individuals have the right to be notified.

Accounting of disclosures. All our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented - for example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. to obtain an accounting of disclosures, you must submit your request in writing to All requests for an “accounting of disclosures” must state a time period, which may not be longer than six years from the date of disclosure. The first list you request within a 12-month period is free of charge, but our practice may charge you for any additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Electronic Copies. Our practice maintains its records in electronic format. Therefore, if you request copies of your records they can be released to you in electronic format if they are requested by you.

Right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice. Contact below:

Privacy Officers 16970
Dallas Parkway, Suite 500
Dallas, Texas 75248
or you may call 972-248-9455

Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact, All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Right to provide an authorization for other uses and disclosures Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Again, if you have any questions regarding this notice or our health information privacy policies, please contact 972-769-PAIN (7246).

Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.

Military Our practice may disclose your PHI if you are a member of U.S. intelligence and national security activities authorized by law.

Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.

Worker’s compensation.  Our practice may release your PHI for worker’s compensation and similar programs.

Other. Other uses and disclosures will be made only with your written authorization and you may revoke the authorization except to the extent the practice has taken action in reliance on such. Examples of uses and disclosures which require your authorization include uses or disclosures (i) of psychotherapy notes except in certain circumstances, (ii) for certain marketing purposes, and (iii) in the case of the sale of your PHI to a third party.

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