NOTICE OF PRIVACY PRACTICES

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.

If you have any questions about this Notice please contact our Privacy Officer or any staff member in
our Office.

Privacy offices Oty enon MUG Contact number: (WWI a4 \ \

External HIPAA Privacy and Security Resource contact: David Wornica, CHPSE. Contact number: 469-
342-8300 ext. 628.

This Notice of Privacy Practices describes how we may use and disclose your protected health
information to carry out your treatment, collect payment for your care and manage the operations of
this clinic. It also describes our policies concerning the use and disclosure of this information for
other purposes that are permitted or required by law. It describes your rights to access and control
your protected health information. “Protected Health Information” (PHI) is information about you,
including demographic information that may identify you, that relates to your past, present, or future
physical or mental health or condition and related health care services.

We are required by Federal law to abide by the terms of this Notice of Privacy Practices. We may
change the terms of our notice at any time. The new notice will be effective for all protected health
information that we maintain at that time. You may obtain revisions to our Notice of Privacy Practices
by accessing our website, calling the office and requesting that a revised copy be sent to you in the
mail or asking for one at the time of your next appointment.

A. Uses and Disclosures of Protected Health Information

By applying to be treated in our office, you are implying consent to the use and disclosure of your
protected health information by your doctor, our office staff and others outside of our office that are
involved in your care and treatment for the purpose of providing health care services to you. Your
protected health information may also be used and disclosed to bill for your health care and to
support the operation of the practice.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOUR IMPLIED
CONSENT

Following are examples of the types of uses and disclosures of your protected health care
information we will make, based on this implied consent. These examples are not meant to be
exhaustive but to describe the types of uses and disclosures that may be made by our office.

Treatment: We will use and disclose your protected health information to provide, coordinate, or
manage your health care and any related services. This includes the coordination or management of
your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as
necessary, to another physician who may be treating you. Your protected health information may be
provided to a physician to whom you have been referred to ensure that the physician has the
necessary information to diagnose or treat you.

In addition, we may disclose your protected health information from time-to-time to another physician
or health care provider (e,g,, a specialist or laboratory) who, at the request of your doctor, becomes
involved in your care by providing assistance with your health care diagnosis or treatment.

Payment: Your protected health information will be used, as needed, to obtain payment for your
health care services, This may include certain activities that your health insurance plan may
undertake before it approves or pays for the health care services we recommend for you such as
making a determination of eligibility or coverage for insurance benefits, reviewing services provided
to you for medical necessity, and undertaking utilization review activities, For example, obtaining
approval for procedures may require that your relevant protected health information be disclosed to
the health plan to obtain approval for those services.

Healthcare Operations: We may use or disclose, as needed, your protected health information in
order to support the business activities of this office, These activities may include, but are not limited
to, quality assessment activities, employee review activities and staff training.

For example, we may disclose your protected health information to interns or precepts that see
patients at our office, In addition, we may use a sign-in sheet at the registration desk where you will
be asked to sign your name and indicate your doctor. Communications between you and the doctor or
his assistants may be recorded to assist us in accurately capturing your responses, We may also call
you by name in the reception area when your doctor is ready to see you, We may use or disclose your
protected health information, as necessary, to contact you to remind you of your appointment.

We will share your protected health information with third party “Business Associates” that perform
various activities (e,g,, billing, transcription services for the practice), Whenever an arrangement
between our office and a Business Associate involves the use or disclosure of your protected health
information, we will have a written agreement with that Business Associate that contains terms that
will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with
information about treatment alternatives or other health-related benefits and services that may be of
interest to you, We may also use and disclose your protected health information for other internal
marketing activities, For example, your name and address may be used to send you a newsletter
about our practice and the services we offer. We may also send you information about products or
services that we believe may be beneficial to you, You may request that these materials not be sent to
you.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION THAT MAY BE MADE WITH
YOUR WRITTEN AUTHORIZATION

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below.

For example, with your written, signed authorization, we may use your demographic information and
the dates that you received treatment from our office, as necessary, in order to contact you for
fundraising activities supported by our office.

You may revoke any of these authorizations, at any time, in writing, except to the extent that your
doctor or the practice has taken an action in reliance on the use or disclosure indicated in the
authorization.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITH YOUR
AUTHORIZATION OR OPPORTUNITY TO OBJECT

In the following instance where we may use and disclose your protected health information, you have
the opportunity to agree or object to the use or disclosure of all or part of your protected health
information. If you are not present or able to agree or object to the use or disclosure of the protected
health information, then your doctor may, using professional judgment, determine whether the
disclosure is in your best interest. In this case, only the protected health information that is relevant to
your health care will be disclosed.

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a
relative, a close friend or any other person you identify, your protected health information that directly
relates to that person’s involvement in your health care. If you are unable to agree or object to such a
disclosure, we may disclose such information as necessary if we determine that it is in your best
interest based on our professional judgment. We may use or disclose protected health information to
notify or assist in notifying a family member, personal representative or any other person that is
responsible for your care of your location or general condition. Finally, we may use or disclose your
protected health information to an authorized public or private entity to assist in disaster relief efforts
and to coordinate uses and disclosures to family or other individuals involved in your health care.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT
YOUR AUTHORIZATION OR OPPORTUNITY TO OBJECT

We may use or disclose your protected health information in the following situations without your
consent or authorization. These situations include:

Required By Law: We may use or disclose your protected health information to the extent that the use
or disclosure is required by law. The use or disclosure will be made in compliance with the law and
will be limited to the relevant requirements of the law. You will be notified, as required by law, of any
such uses or disclosures.

Public Health: We may disclose your protected health information for public health activities and
purposes to a public health authority that is permitted by law to collect or receive the information. The
disclosure will be made for the purpose of controlling disease, injury or disability. We may also
disclose your protected health information, if directed by the public health authority, to a foreign
government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to
a person who may have been exposed to a communicable disease or may otherwise be at risk of
contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for
activities authorized by law, such as audits, investigations, and inspections. Oversight agencies
seeking this information include government agencies that oversee the health care system,
government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that
is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your
protected health information if we believe that you have been a victim of abuse, neglect or domestic
violence to the governmental entity or agency authorized to receive such information. In this case, the
disclosure will be made consistent with the requirements of applicable Federal and state laws.

Legal Proceedings: We may disclose protected health information in the course of any judicial or
administrative proceeding, in response to an order of a court or administrative tribunal (to the extent
such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery
request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal
requirements are met, for law enforcement purposes. These law enforcement purposes include (I)
legal process and otherwise required by law, (2) limited information requests for identification and
location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a
result of criminal conduct, (5) in the event that a crime occurs on the premises of the Practice, and (6)
medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.

Workers’ Compensation: We may disclose your protected health information, as authorized, to comply
with workers’ compensation laws and other similar legally-established programs.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required
by the Secretary of the Department of Health and Human Services to investigate or determine our
compliance with the requirements of Section 164.500 et. seq.

B. Your Rights

Following is a statement of your rights with respect to your protected health information and a brief
description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may
inspect and obtain a copy of protected health information about you that is contained in a designated
record set for as long as we maintain the protected health information. A “designated record set”
contains medical and billing records and any other records that your doctor and the Practice uses for
making decisions about you.

Under Federal law, however, you may not inspect or copy the following records: psychotherapy notes;
information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action
or proceeding, and protected health information that is subject to law that prohibits access to
protected health information. Depending on the circumstances, a decision to deny access may be
reviewed. In some circumstances, you may have a right to have this decision reviewed. Please ask
your doctor if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may
ask us not to use or disclose any part of your protected health information for the purposes of
treatment, payment or healthcare operations. You may also request that any part of your protected
health information not be disclosed to family members or friends who may be involved in your care or
for notification purposes as described in this Notice of Privacy Practices. Your request must be in
writing and state the specific restriction requested and to whom you want the restriction to apply.

Your provider is not required to agree to a restriction that you may request. If the doctor believes it is
in your best interest to permit use and disclosure of your protected health information, your protected
health information will not be restricted. If your doctor does agree to the requested restriction, we
may not use or disclose your protected health information in violation of that restriction unless it is
needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to
request with your doctor.

You may request a restriction by presenting your request, in writing to a staff member in our office.
The staff member will provide you with “Restriction of Consent” form. Complete the form, sign it, and
ask that the staff member provide you with a photocopy of your request initialed by them. This copy
will serve as your receipt.

You have the right to request to receive confidential communications from us by alternative means or
at an alternative location. We will accommodate reasonable requests. We may also condition this
accommodation by asking you for information as to how payment will be handled or specification of
an alternative address or other method of contact. We will not request an explanation from you as to
the basis for the request. Please make this request in writing.

You may have the right to have your doctor amend your protected health information. This means you
may request an amendment of protected health information about you in a designated record set for
as long as we maintain this information. In certain cases, we may deny your request for an
amendment. If we deny your request for amendment, you have the right to file a statement of
disagreement with us and we may prepare a rebuttal to your statement and will provide you with a
copy of any such rebuttal. Please ask your doctor if you have questions about amending your medical
record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your
protected health information. This right applies to disclosures for purposes other than treatment,
payment or healthcare operations as described in this Notice of Privacy practices. It excludes
disclosures we may have made to you, to family members or friends involved in your care, pursuant

to a duly executed authorization or for notification purposes. The right to receive this information is
subject to certain exceptions, restrictions and limits.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed
to accept this notice electronically.

C. Complaints

You may complain to us, to the Texas Attorney General’s Office, or the Secretary of Health and
Human Services, if you believe your privacy rights have been violated by us. You may file a complaint
with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing
a complaint.

You may contact our Privacy Officer in writing at our office address. Our website may offer additional
information about the complaint process.

This notice was published and becomes effective on December 10, 2024.