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Privacy Practices

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how health information about you may be used or disclosed and how you can get access to your protected health information (PHI); effective date 4/14/2003.



Our practice is dedicated to maintaining the privacy of your Protected Health Information (PHI). Your PHI includes any individually identifiable information held by our practice i.e. medical information, billing information, etc. We are required by law to provide you with this Notice of our Privacy Practices. We will follow the terms of this notice. We reserve the right to revise or amend this notice.


Privacy Officer
12201 Renfert Way #220
Austin, TX 78758

Phone: 512.425.3825
Fax: 512.425.3829


  1. Treatment. We may use and disclose your PHI for your treatment and to provide you with treatment related health care services. For example, we may disclose your PHI to doctors, nurses, technicians or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.
  2. Payment. We may use and disclose your PHI so that we or others may bill and receive payment from you, an insurance company or a third party for treatment/services you received.
  3. Health Care Operations. Our practice may use and disclose your PHI to operate our business. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to manage/operate our office.
  4. Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.
  5. Release of Information to Family/Friends. When appropriate, we may share your PHI with a person who is involved in your medical care or payment for your care.
  6. 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.


  1. Public Health Risks. Our practice may disclose your PHI for public health reasons. These reasons will generally include disclosures to prevent/control disease, injury, or disability; report births and deaths; report child abuse/neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; inform a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and report to the appropriate government authority if we believe a patient has been a victim of abuse, neglect or domestic violence. These disclosures will only be made if you agree or when required by law.
  2. Health Oversight Activities. Our practice may disclose your PHI to health oversight agencies for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, licensure; or other activities necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.
  3. 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. This may include discovery request, subpoena, or other lawful process by another party involved in the dispute. We will make every reasonable effort to inform you of these requests.
  4. Law Enforcement. We may release PHI if asked to do so by a law enforcement official if the information is: regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement; concerning a death we believe has resulted from criminal conduct; regarding criminal conduct at our offices; in response to a warrant, summons, court order, subpoena or similar legal process; to identify/locate a suspect, material witness, fugitive or missing person; in an emergency, to report a crime.
  5. Deceased Patients. 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 in order for funeral directors to perform their jobs.
  6. Organ and Tissue Donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
  7. 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.
  8. 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. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
  9. Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
  10. National Security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
  11. 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. Disclosure for these purposes would be necessary for the institution to provide health care services to you; for the safety/security of the institution; to protect your health/safety or the health/safety of other individuals.
  12. Workers’ Compensation. Our practice may release your PHI for workers’ compensation and similar programs.



Privacy Officer
12201 Renfert Way #220
Austin, TX 78758

  1. Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. Your written request must include how or where you wish to be contacted. Our practice will accommodate reasonable requests.
  2. Requesting Restrictions. You have the right to request a restriction in our use/disclosure of your PHI for treatment, payment or health care operations. 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 members and friends. We arenot 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. You must make this request in writing by completing the appropriate form available at the front desk; you must describe in a clear and concise fashion the information you wish restricted and to whom you want the limits to apply.
  3. Requesting a Copy of your PHI. You have the right to request a copy of your PHI, including billing records. You must make this request in writing by complete our standard release of records form available at the front desk. Our practice may charge a fee for this request and may take up to 30 days to fulfill the request. Our practice may deny your request in certain circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
  4. Amendment. You may request to amend your health information if you believe it is incorrect or incomplete. You must make this request in writing by completing the appropriate form available at the front desk. Your amendment will become part of your PHI for as long as the information is kept by and for our office.
  5. Accounting of Non-authorized, Non-routine Disclosures. You have the right to request a listing of non-authorized, non-routine disclosures (meaning not related to treatment, payment or operations). In order to obtain a listing of these disclosures, you must complete the appropriate form available at the front desk. All requests must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003.
  6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices.
  7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a written complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, complete the form available at the front desk.

Updated 1/05

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