Your Right to Privacy

HIPAA Acknowledgement Notice


Uses and Disclosures of Protected Health Information Without Patient's Authorization

There are several circumstances in which we are allowed to use or disclose your health data without your authorization:
  • if the disclosure is related to your treatment,
  • if it is necessary for payment for our health care services, or
  • if we need to disclose it in carrying out our business or healthcare operations.
Texas residents: Beginning September 1, 2012, we are also allowed to disclose your health data without your authorization to perform insurance or health maintenance organization (HMO) functions defined by Section 602.053, Insurance Code. Examples of each kind of release are given in the sections below. We will only use or disclose your protected health information when the law allows or requires us to do so. Any other use or disclosure will be made only with your prior authorization, and if you revoke that authorization, no further use or disclosure will be made; however, information which was released while your authorization was in effect will not be recalled. Texas residents: beginning on September 1, 2012, for any disclosure other than those we’re either permitted or required by law to make, we have to get a separate authorization from you before each disclosure. That authorization can either be in writing or oral. If it’s oral, we will note it in your records.


From time to time, our doctor(s) may decide you need to be seen by a specialist. The specialist can’t tell what kind of treatment you need without seeing your health records, so we send them to the specialist for review. This kind of disclosure doesn’t require your consent.

Disclosures to Facilitate Payment for Our Services:

Many patients have medical insurance that pays for their treatment. Since the insurer requires your medical information in order to properly pay us for providing that treatment, we send them what they need in order to properly classify and pay for the treatment. This kind of disclosure doesn’t require your consent.

Health Care Operations:

We are allowed to disclose your medical information if that is necessary for our office to function efficiently. There are also times when we may need the help of a special vendor, such as a medical billing specialist, and we would then send your records to that vendor in order for us to carry on our business. There are certain other occasions when we are lawfully allowed to use or disclose your health information without your authorization. Those situations are more than likely what you would expect from us, but just so you are aware of them, they are:
  • When required by law: If the use or disclosure of your medical information is required of us by law, we will comply with the law but will limit our use or disclosure to the relevant requirements of the law.
  • For certain limited public health activities: There are certain authorities (like the Food and Drug Administration), which are authorized to collect information for the purpose of preventing or controlling disease or injury. Other agencies, such as those that obtain information regarding child abuse reports, also require information from physician offices. Still others have the right to obtain personal data to maintain vital statistics (such as birth and death records). If one of these agencies requires us to give them your health data, we will.
  • Necessary for the reporting of victims of abuse, neglect or domestic violence: If, in the exercise of our professional judgment, we believe disclosure is necessary to prevent serious harm, we will provide your health data to any governmental authority authorized by law to receive reports of abuse, neglect or domestic violence.
  • For certain health oversight activities: Sometimes we are asked to provide information to oversight agencies for activities authorized by law. These activities include, but are not limited to, criminal investigations, civil rights inquiries, inspections, audits, and work of that nature. We will cooperate with these legal authorities and provide data to them as per their statutory authorizations.
  • For judicial and administrative proceedings: We will also disclose your health data if we are required to do so under a Court order or subpoena. If we receive this kind of a request, we will make sure that the inquiry fits the criteria we must follow for release of your data for these proceedings. Those criteria require that we only release information sought for a specific request that has a legitimate purpose. We cannot and will not produce more data than we have to and we will try to delete as much of your personal information as the law will allow.
  • For law enforcement purposes: The law allows us to disclose your medical information in response to legitimate lawful requests (such as from a legitimate law enforcement agency or in response to a subpoena) as follows: a) if the law requires the reporting of certain types of injuries; b) if the data is sought to help the law enforcement agencies locate a suspect, fugitive or missing person (and then we only have to provide limited descriptive data); c) if the request relates to a crime victim or some one who has died; or d) if there has been a crime on our office premises.
  • About decedents: If asked, we may disclose health data for the purposes of identifying someone who has died. Sometimes, funeral directors need health data in order to perform their duties. In those cases, we may also provide that information.
  • For cadaveric organ, eye or tissue donation purposes: The law allows us to provide health data for organ donations.
  • For research: If the appropriate authorities approve the privacy protection policies of a research organization, we may allow the disclosure of health information to the research organization.
  • To avert a serious threat to health or safety: We may also choose to report health data if we believe that is necessary to diminish a threat to anyone's health or safety.
  • For specialized government functions: There are certain instances involving the government wherein we will provide your health data consistent to the applicable law. These involve veterans who need medical data for continued benefits or for armed services personnel who are leaving their branch of the service. We will also provide health data for national security and intelligence purposes or for protective services for the President of the United States or some foreign dignitaries.
  • For limited purposes for worker's compensation: We are allowed to give out your health information as authorized in order to comply with workers compensation or work-related injury laws or proceedings.
This Notice is effective as of 9 January 2012. From time to time, we may revise our Notice. If we do, we will post the most current version in our office, and you may ask for a copy of the Notice at any time.

Patients' Rights to Protected Health Information

  • You have the right to request that we restrict our disclosures of your medical information, and some states have more stringent medical privacy restrictions than HIPAA requires. You may ask that we limit the use and disclosure of your health information; we are not required to accept your request. IF we do agree, however, we will do as you wish except in an emergency. You may submit your request to us in writing (to the person at the bottom of this Notice) and tell us: a) what information you want us to limit b) how you want us to limit that data and c) to whom we are to limit the access to this data. You may also ask that we restrict the disclosure of your health information to only certain people.
  • You have the right to receive confidential communication by alternate means or at alternate locations. You may ask us to send your information to you at an address that is different from the one you've asked us to use. Please make that request in writing to our Privacy Officer at the address at the bottom of this Notice. We will agree, so long as your request is reasonable, but you must tell us how to communicate with you and you must give us a complete address or contact information.
  • You have the right to request access to your medical information maintained in the medical or billing records (or any of the records that we rely upon for decisions about your medical treatment) except for a) psychotherapy notes; b) information that we gather in preparation of an administrative action or proceeding; c) data that is subject to certain provisions of the Clinical Laboratory Improvements Act. We may deny your request (in writing) under certain limited circumstances and there are some situations in which you may appeal our decision to deny your request. Generally, if we agree to provide you with a copy of your records, we will do so within 30 days after you ask for it, so long as your chart is in our office. We will charge you a reasonable, cost-based fee for the records*.
  • You have the right to ask us to amend your medical information. We have the right to deny that request if you ask about medical information that a) was not created by any of our doctors; b) the information is not part of the medical or billing records (or any of the records that we rely upon for decisions about your medical treatment); c) is not part of the records you may access or d) the medical information is accurate and complete. We may ask that you tell us, in writing, why you want us to amend your medical information. Generally, we must act upon your request within 60 days after receipt of your request. If we agree to your request, we must make the appropriate amendment and follow the law regarding how and whom we inform about this amendment. If we do not agree, then we will tell you our reasons. You then have additional rights, including an appeal (by someone who did not participate in the decision not to allow you to amend your record) and you have the right to submit a written statement of disagreement.
  • You have the right to know how and to whom we've used or disclosed any of your medical information that identifies you. We are required to give you that data except for any use or disclosure: a) for treatment, payment and/or health care operations; b) made with your authorization; c) that we make to you; d) for any national security or intelligence purposes; e) made before 14 April 2003; or f) that does not require your authorization. We will provide this data to you (generally, within 60 days) at no charge once each year, but after that, we will require that you pay a reasonable fee-based charge for the information.
*Texas residents: under Section 181.102, Texas Health and Safety Code, beginning on September 1, 2012, if you request your electronic medical records in writing, we are required to provide you with those records within fifteen (15) days. We will provide them in electronic form unless you ask for them in another form.

How We Communicate with You

We believe that it is important for you to have access to extremely important medical information as soon as it is available. For that reason, we may leave a message for you on your answering machine and ask that you call us back to discuss this matter. Our doctor(s) sometimes need to be able to communicate quickly about your health information, too. For example, if you have a medical emergency, our doctor(s) may get a page and will return that call on a cell phone. These days, conversations on cell phones are not completely secure, but they are often the fastest method of communication. We also understand that with all that you do in your life, you may not remember to call us for your next visit. For that reason, we will send you a reminder of your next appointment with our doctor(s). From time to time, we may also contact you to let you know of health services we have developed in our office.

Filling a Complaint of Privacy Practices

If you believe that we have somehow failed to follow our Privacy Policies, please contact our Chief Privacy Officer at the address at the bottom of our Notice. We cannot and will not retaliate against you if you file a complaint. You also have the right to file a complaint with the Secretary of Health and Human Services.

Click the link below for information on how to file a complaint to the U.S Department of Health and Human Services.

Our Privacy Officer

If you have any questions or comments about this notice, please contact our Chief Privacy Officer.

  • Name of CPO: Mike Rouse
  • Address: 13409 George Road, San Antonio, TX 78230
  • Phone: 210-492-8922, Fax: 210-479-2010
  • Or you may email the CPO directly using the form below.

This form is not for Clinical Use. Do not send protected health information through this form. Contact our office at 866-412-6503 for instructions on sending confidential medical information. If there is a medical emergency, dial 9-1-1.