3300 Oak Lawn Ave, Suite 200
Dallas, TX 75219
Privacy Officer: Jeremy Bates, MD
PHONE # 214-765-9661


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 at that time. The new notice will be available upon request, in our office, and on our web site.

Your Rights

The following is a statement of your rights with respect to your personal medical information and a brief description of how you may exercise these rights:

  • Get an electronic or paper copy of your medical record: You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you in a “designated record set,” which is the set of medical and billing records and any other records we
    use to make decisions about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, costbased fee. We will honor all requests for us to provide you with electronic access to your protected health information if such access can be reasonably provided by us.
  • Ask us to correct your medical record: You can ask us to correct health information we maintain in a “designated record set” about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but if you file a statement of disagreement, we will prepare a rebuttal to your statement and provide you with a copy of our rebuttal.
  • Request confidential communications: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. We may condition the accommodation by asking you for information as to how payment will be handled or to specify the alternative address or contact method. We will not ask you to tell us why you are requesting the alternative means or location of contact. Any request may be made in writing to the Privacy Officer.
  • Request restrictions on what we use or share: You may ask us not to use or share certain health information for treatment, payment, or our operations, or you may ask us not to share information with family members or friends involved in your care or for notification purposes. You
    must provide us with the specific restriction and to whom you want the restriction to apply. 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 health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. If we 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 us. You may request a restriction by designating that restriction in writing.
  • Get a list of those with whom we’ve shared information: You can ask for a list (an “accounting”) of the disclosures we have made of your health information for up to six years prior to the date of your request, 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, to family and friends involved in your care or to notify them, or to a facility directory). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
  • Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
  • 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. We will make sure the person has this authority and can act for you before we take any action.
  • File a complaint if you feel your rights are violated: You can complain if you feel we have violated your rights by contacting the Privacy Officer, whose name and contact information is listed at the beginning of this Notice. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting  We will not retaliate against you for filing a complaint.

Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information in the following ways:

  • Your Treatment: We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
  • Practice Management and Operations: We can use and share your health information to run our practice, improve your care, and generally support the business activities of the practice. Example: We use health information about you to manage your treatment and services.
  • Payment and Billing: We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

What choices to do you have with respect to our disclosures? You have the right and choice to tell us whether or not you want us to share information:

(1) with your family, friends or others involved in your care,
(2) in a disaster relief situation, or
(3) for a facility directory.

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. If you have a clear preference for how we share your information in the situations described below, please let us know. Tell us what you want us
to do, and we will follow your instructions.

When will we ask for your authorization? We will never share your information for the following purposes unless you give us written authorization for the following uses and disclosures: marketing, the sale of your information, or sharing of psychotherapy notes. If you decide you no longer want us disclosing your information for those authorized purposes, you can revoke your authorization at any time in writing. To the extent we disclose patient information electronically, we will seek your separate authorization to do so, except for electronic disclosures made to other providers or health plans for your treatment, for payment, for our own operations, or as otherwise authorized or required by state or federal law. In the case of fundraising, we may contact you for fundraising efforts, but you can “opt out” and tell us not to contact you again.

How else can we use or share your health information? 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:

  • Help with public health and safety issues: We can share health information about you for certain situations such as: preventing disease; helping with product recalls; reporting adverse reactions to medications, including reports to the FDA; 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 information for health research.
  • Comply with the law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
  • Respond to organ and tissue donation requests: We can share health information about you with organ procurement organizations.
  • Address workers’ compensation, law enforcement, health oversight and other government requests: We can use or share health information about you for workers’ compensation claims, for law enforcement purposes or with a law enforcement official, when there is a crime on the premises, with health oversight agencies for activities authorized by law (such as licensure or administrative actions), or for special government functions such as military, national security, and secret service activities.
  • 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 subpoena.
  • Research: We may use your PHI to conduct research and we may disclose your PHI to researchers as authorized by law. For example, we may use or disclose your PHI as part of a research study when the research has been approved by an institutional review board or privacy board and has received the research proposal and established privacy protocols.
  • Medical Examiners/Coroners, Funeral Directors: We may release your PHI to coroners or medical examiners to carry out their duties, including the identification of a deceased person or to determine cause of death. We may also disclose to funeral directors in the course of their duties.
  • Organ or Tissue Procurement: Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other organ and/or tissue donation services.
  • Correctional Institutions: If you are or become an inmate, we may disclose your PHI to the institution or its agents holding you, as necessary for the health and safety of you or others.

Our Responsibilities

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

For more information see:

To Download or Print a copy of this document, please click here.

The effective date of this Notice is August 15, 2016.