Notice of Privacy Practice



• This notice describes the practices of our employees and staff as well as volunteers, and any healthcare entities and medical offices owned by or affiliated with this facility. This notice applies to each of these individuals, entities, sites, and locations. In addition, these individuals, entities, sites and locations may share medical information with each other for treatment, payment and health care operation purposes described in this notice.


In the ordinary course of receiving treatment and healthcare services from us, you will be providing us with personal information such as:

•       Your name, date of birth, social security number, address, phone numbers

•       Information regarding your medical history

•       Your insurance information and coverage

•       Information concerning your doctor, nurse, or other medical providers

•       Emergency contacts

In addition, we will gather certain medical information about you and will create a record of the care provided to you. Some information also may be provided to us by other individuals or organizations that are part of your “circle of care” – such as the referring physician, your other doctors, your health plan, and close friends or family members.


The following categories describe different ways we use and disclose medical and billing information. We will supply some examples for each category; however, every use or disclosure in the category will not be listed.

Required Disclosures. We are required to disclose health information about you to the Secretary of Health and Human Services, upon request, to determine our compliance with HIPAA and to you, in accordance with your rights to access and right to receive an accounting of disclosures, as described below.

For Treatment. We may use health information about you in your treatment. For example, we may use your medical history to assess the health of your eyes or GI tract.

For Payment. We may use and disclose health information about you to bill for our services and to collect payment from you or your insurance company. For example, if your policy has a preexisting clause, we will need to provide your medical information to your insurance company for review prior to payment or processing of the claim.

For Health Care Operations. We may use and disclose information about you for the general operation of our business. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.

Public Policy Uses and Disclosures. There are a number of public policy reasons why we may disclose information about you. We may disclose information about you when we are required by federal, state, or local law. We may disclose protected health information about you in connection with certain public health reporting activities (Ex. preventing or controlling disease). We may disclose protected health information to a public health authority or other governmental authority in cases of child or adult abuse or neglect. We may disclose protected health information to a person subject to the Food and Drug Administration’s power (Ex. reporting adverse effects, defective products, etc.). We may disclose a patient’s health information to a person who may have been exposed to a communicable disease or to an employer to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether an individual has a work-related illness or injury. We may disclose health information about you in connection with certain health oversight activities of licensing and other health oversight agencies which are authorized by law. We my disclose your health information as required by law, including in response to a warrant, subpoena, or other order of a court or administrative hearing body or to assist law enforcement identify or locate a suspect, fugitive, material witness, missing person, victims of crimes, and death of an individual. We may disclose information to a coroner/medical examiner and funeral directors. We may disclose your health information to transplant centers if you an organ donor. We may disclose your health to workers’ compensation or similar programs (work-related injuries/illness). We may disclose your health information in order to prevent a serious threat to your health and safety or the health and safety of others. We may use your health information for research purposes. If you are a member of the Armed Forces, your personal health information may be released for activities deemed necessary by military command authorities. We may disclose your protected health information for legal or administrative proceedings that involve you. If you an inmate, we may release your protected health information about you to the correctional institution or law enforcement officers in certain situations such as where the information is necessary for your treatment, health, or safety of others. We may disclose protected health information for national security and intelligence activities and for the provision of protective services to the President of the United States and other officials or foreign heads of state.

Our Business Associates. We sometimes work with outside individuals and business that help us operate our business successfully. We may disclose your health information to these business associates so that they can perform the tasks that we hired them to do. Our business associates must promise that they will respect the confidentiality of your personal and identifiable health information.

Disclosures to Persons Assisting in Your Care or Payment for Your Care. We may disclose information to individuals involved in your care or in the payment for your care (Ex. spouse, other doctors, etc.). We may disclose also use and disclose health information about a patient for disaster relief efforts and to notify persons responsible for a patient’s care about a patient’s location, general condition or death. Generally, we will obtain your verbal agreement before using or disclosing health information in this way. However, under certain circumstances, such as in an emergency situation, we may make these uses and disclosures without your agreement.

Appointment Reminders. We may use or disclose medical information to contact you as a reminder that you have an appointment, that you should schedule an appointment or that you have missed an appointment.

Treatment Alternatives. We may use and disclose your personal health information in order to tell you about or recommend possible treatment options, alternatives or health-related services that may be of interest to you.

Fundraising. We may use your protected health information to contact you in an effort to raise funds for our operations.

OTHER USES AND DISCLOSURES OF PERSONAL INFORMATION. We are required to obtain written authorization from you for nay other uses and disclosures of medical information other than those described above. If you provide us with such permission, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by your written authorization, except to the extent we have already relied on your original permission.


You have the right to ask for restrictions on the ways we use and disclose your health information for treatment, payment, and healthcare operation purposes. You may also request that we limit our disclosures to persons assisting your care or payment for your care. We will consider your request, but we are not required to accept it. You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail. Except under certain circumstances, you have the right to inspect and copy medical, billing and other records used to make decisions about you. If you ask for copies of this information, we may charge you a fee for copying and mailing. If you believe that information in your records is incorrect or incomplete, you have the right to ask us to correct the existing information or add missing information. Under certain circumstances, we may deny your request, such as when the information is accurate and complete. You have the right to receive a list of certain instances when we have used or disclosed your medical information. We are not required to include in the list uses and discloses for your treatment, payment for services furnished to you, our health care operations, disclosures to you, disclosures you give us authorization to make and uses and disclosures before April 14, 2003, among others. If you ask for this information from us more than once every twelve months, we may charge you a fee. You have the right to a copy of this notice in paper form. You may ask us for a copy at any time. To exercise any of your rights, please contact us in writing at 6500 Sierra Drive, Suite 170 Irving, Texas 75039. When making an amendment, you must state a reason for making the request.


We reserve the right to make changes to this notice at any time. We reserve the right to make the revised notice effective for personal health information we have about you as well as any information we receive in the future. In the event there is a material change to this notice, the revised notice will be posted. In addition, you may request a copy of the revised notice at any time.


If you have any complaints concerning our privacy practices, you may contact the Secretary of the Department of Health and Human Services at 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201 (e-mail: You may also contact us at 6500 Sierra Drive, Suite 170 Irving, Texas 75039 and phone number is 972-331-1590.