NOTICE OF PRIVACY PRACTICES

Dear Patient,

Thank you for choosing OrthoLoneStar to provide your musculoskeletal care. In compliance with HIPAA, we would like to make you aware of your rights and our uses and disclosures as it pertains to your Personal Health Information.

YOUR CHOICE.

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

• In these cases, you have both the right and choice to tell us to:
  • Share information with your family, close friends, or others involved in your
  • Share information in a disaster relief

*If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.*

• In these cases, we never share your information unless you give us written permission
  • Marketing purposes
  • Sale of your information
  • Sharing of psychotherapy notes
• In the case of Fundraising:
  • If we contact you for any community relief efforts, you can tell us not to contact you

YOUR RIGHTS.

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

• Get an electronic or paper copy of your
  • We will provide a copy of your health information, usually within 15 days of your We may charge a reasonable, cost- based fee. We may contract with a third party to perform this service.
• Ask us to correct your medical
  • You can ask us to correct information that you think is incorrect or
  • We may say “no” to your request, but we’ll tell you why in writing within 60
• Request confidential
  • You can ask us to contact you in a specific way (for example, cell, home or office phone) or to send mail to a different
  • We will say “yes” to all reasonable
• Ask us to limit what we use or
  • You can ask us NOT to use or share certain health information for treatment, payment, or our We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or healthcare item in full, out-of-pocket, you can ask us not to share that information with your health insurer. We will say “yes” unless a law requires us to share that information.
• Get a copy of this privacy
  • You can ask for a paper copy of this notice at any It is also available on our website
• Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. Please provide us with a copy of this documentation.
• File a complaint if you feel your rights are
  • Please let us know if you have any questions, concerns or You may contact the OrthoLoneStar Privacy Officer, 7401 Main Street, Houston, TX 77030, 713-794-3352 or privacy@ortholonestar.com. We also have a manager at each location available for you to speak with.
  • You can file a complaint with the Region VI, Office for Civil Rights, S. Department of Health & Human Services at to 1301 Young Street, Suite 1169, Dallas, TX 75202
  • We will not retaliate against you for filing a complaint
• Get a list of those with whom we’ve shared
  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment and health care operations, and certain other disclosures (such as any you asked us to make).

OUR USES & DISCLOSURES.

We typically use or share your health information in the following ways:

• Treat
  • We can use your health information and share it with other professionals who are treating
  • To access your pharmacy benefits data for; formulary check, prescriptive history and electronic
• Run our
  • We can use and share your health information to run our practice, improve your care, and contact you when
  • We use email and text (SMS) technology for appointment reminders and form You have the option to opt out of these messages.
  • We may contact you with relevant health information, research, initiatives, or You have the option to opt out of these notifications.
• Bill for your services
  • We can use and share your health information to bill and get payment from health plans or other

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index/html

• Help with public health and safety issues
  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety
• Do research
  • We can use or share your anonymized information for health
• Comply with the law, address workers’ compensation, law enforcement, and other gov’t requests
  • We will share information about you if state or federal laws require it, including in compliance with the Department of Health and Human Services.
  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services
• Respond to organ and tissue donation requests
  • We can share health information about you with organ procurement
• Work with a medical examiner or funeral director
  • We can share health information with a coroner, medical examiner, or funeral director when an individual
• Respond to lawsuits and legal actions
  • We can share health information about you in response to a court or administrative order, or in response to a

OUR RESPONSIBILITIES.

• We are required by law to maintain the privacy and security of your protected health
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your
• We must follow the duties and privacy practices described in this notice and give you a copy of it upon
• We will not use or share your information other than as described here unless you tell us we can in You may change your mind at any time, by notifying us in writing.

CHANGES TO THE TERMS OF THIS NOTICE

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Patient Signature:	Date:
If a patient is a minor (under the age of 18) or incapacitated:
Responsible Party Name:	Relationship to Patient:
Responsible Party Signature:	Date: