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.
Our Privacy Officer is Jim Moore - 469.342.8300, Extension 508
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.
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Subash Mutyala DDS
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 will
ask for your authorization. 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.
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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 Consent, 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.
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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.
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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.
Our Privacy Officer is Jim Moore, a Certified HIPAA Professional. You may contact our Privacy Officer in writing
at our office address or by calling 469.342.8300, Extension 508. Our website may offer additional information
about the complaint process.
This notice was published and becomes effective on May 15, 2017.
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Privacy Policy