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Notice of Privacy Practices

Notice of Privacy Practices

Texas Back Institute has adopted the following privacy policies. 
Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed to other health care 
professionals for the purpose of evaluating your health, diagnosing medical conditions, and 
providing treatment. For example, results of laboratory tests and procedure will be available in 
your medical record to all health professionals who may provide treatment or who may be consulted 
by staff members.

Payment. Your health information may be used to seek payment from your health plan, from other 
sources of coverage such as an automobile insurer, or from credit card companies that you may use 
to pay for services. For example, your health plan may request and receive information on dates of 
service, the services provided, and the medical condition being treated. 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.

Health care operations. Your health information may be used as necessary to support the day- to-day 
activities and management of Texas Back Institute. For example, information on the services you 
received may be used to support budgeting and financial reporting, and activities to evaluate and 
promote quality.

Law enforcement. Your health information may be disclosed to law enforcement agencies, without your 
permission, to support government audits and inspections, to facilitate law- enforcement 
investigations, and to comply with government mandated reporting.

Public health reporting. Your health information may be disclosed to public health agencies as 
required by law. For example, we are required to report certain communicable diseases to the 
state’s public health department.

Other uses and disclosures require your authorization. Disclosure of your health information or its 
use for any purpose other that those listed above requires your specific written authorization. If 
you change your mind after authorizing a use or disclosure of your information you may submit a 
written revocation of the authorization. However, your decision to revoke the authorization will 
not affect or undo any use or disclosure of information that occurred before you notified us of 
your decision.

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 in order 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.

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 further communications.

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

Additional Uses of Information
Appointment reminders. Your health information will be used by our staff to send you appointment 
reminders by mail or to contact you by phone regarding appointment reminders.

Information about treatments. Your health information may be used to send you information on the 
treatment and management of your medical condition that you may find to be of interest. We may also 
send you information describing other health-related goods and services that we believe may 
interest you.

Individual Rights
You have certain rights under the federal privacy standards. These include:
  1. The right to request restrictions on the use and disclosure of your Protected Health  Information;
  2. The right to receive confidential communications concerning your medical condition and  treatment;
  3. The right to inspect and copy your Protected Health Information;
  4. The right to amend or submit corrections to your protected health information;
  5. Should an unsecured breach of your Protected Health Information occur, all affected individuals  have the right to be notified.
  6. 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.
  7. The right to receive an accounting of how and to whom your protected health information  has been disclosed; and
  8. The right to receive a printed copy of this notice.

Texas Back Institute’s Duties
We are required by law to maintain the privacy of your protected health information and to provide 
you with this notice of privacy practices. We also are required to abide by the privacy policies 
and practices that are outlined in this notice.

Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices.
These changes in our policies and practices may be required by changes in federal and state laws 
and regulations. Whatever the reason for these revisions, we will provide you with a revised notice 
on your next office visit. The revised policies and practices will be applied to all protected 
health information that we maintain.

Requests to Inspect Protected Health Information
As permitted by federal regulation, we require that requests to inspect or copy Protected Health 
Information be submitted in writing. You may obtain a form to request access to your records by 
contacting: Cheryl Zapata, Privacy Officer, 6020 W. Parker Road, Suite 200, Plano, Texas 75093.

If you would like to submit a comment or complaint about our privacy practices, you can do so by 
sending a letter outlining your concerns to: Cheryl Zapata, Privacy Officer, Texas Back Institute, 
6020 W. Parker Rd., Ste. 200, Plano, TX 75093

If you believe that your privacy rights have been violated, you should call the matter to our 
attention by sending a letter describing the cause of your concern to the same address. You will 
not be penalized or otherwise retaliated against for filing a complaint.

Contact Person
The name and address of the person you can contact for further information concerning our
privacy practices is: Cheryl Zapata, Texas Back Institute, 6020 W. Parker Rd., Ste. 200, Plano, TX 

Effective Date
This Notice is effective on or after September 15, 2013.

When finished filling out the form, please click the Submit button.  If you need to come back at a later time to finish the form, please click the Save button and you will be able to start from the point where you left off.