Uma Chintapalli, MD     972-924-2900
701 West White St. Street 2B,  Anna, TX 75409


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.

We respect your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others without your permission, or unless the law authorizes or requires us to do so. The law protects the privacy of the health information we create and obtain in providing our care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations:

For treatment: Information obtained by a nurse, physician, or other members of our health care team will be recorded in your medical record and used to help decide what care may be right for you. We may also provide information to others providing you care. This will help them stay informed about your care.

For payment: We request payment from your health insurance plan. Health plans need information from us about your medical care. Information provided to health plans may include your diagnoses, procedures performed, or recommended care.

For health care operations: We use your medical records to assess the quality and improve services.
We may use and disclose medical records to review the qualifications and performance of our health care providers and to train our staff. We may contact you to remind you about appointments and give you information about treatment alternatives or other health-related benefits and services.

We may use and disclose your information to conduct or arrange for services, including medical quality review by your health plan; accounting, legal, risk management, and insurance services; audit functions, including fraud and abuse detection and compliance programs.

Your Health Information Rights: The health and billing records we create and store are the property of the practice/health care facility. The protected health information in it, however, generally belongs to you.

You have a right to: Receive, read, and ask questions about this Notice; to ask us to restrict certain uses and disclosures. You must deliver this request in writing to us.

Request and receive from us a paper copy of the most current Notice of Privacy Practices for Protected Health Information (“Notice”)

Request that you be allowed to see and get a copy of your protected health information. You may make
this request in writing. We have a form available for this type of request.

Have us review a denial of access to your health information—except in certain circumstances.

Ask us to change your health information:. You may give us this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record, and included with any release of your records. When you request, we will give you a list of disclosures of your health information. The list will not include disclosures to third-party payors. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months.

Ask that your health information be given to you by another means or at another location: Please sign, date, and give us your request in writing.

Cancel prior authorizations to use or disclose health information by giving us a written revocation: Your revocation does not affect information that has already been released. It also does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

For help with these rights during normal business hours, please contact: 972-924-2900.

Our Responsibilities:

We are required to keep your protected health information private; give you this Notice, and follow the terms of this Notice.

We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling and asking for it or by visiting our website to download the most recent copy.

To Ask for Help or Complain: If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact: office manager at 972-596-4200. If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to Office Manager, UCC of Anna, 701 West White St. Street 2B, Anna, TX 75409. You may also file a complaint with the U.S. Secretary of Health and Human Services. We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.

Other Disclosures and Uses of Protected Health Information: Unless you object, we may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital. In addition, we may disclose health information about you to assist in disaster relief efforts. You have the right to object to this use or disclosure of your information. If you object, we will not use or disclose it.

We may use and disclose your protected health information without your authorization as follows:

To Funeral Directors/Coroners consistent with applicable law to allow them to carry out their duties.
To Organ Procurement Organizations (tissue donation and transplant) or persons who obtain store, or transplant organs

To the Food and Drug Administration (FDA) relating to problems with food, supplements, and products.

To Comply With Workers’ Compensation Laws—if you make a workers’ compensation claim.

For Public Health and Safety Purposes as Allowed or Required by Law: to prevent or reduce a serious, immediate threat to the health or safety of a person or the public; to public health or legal authorities; to protect public health and safety; to prevent or control disease, injury, or disability; to report vital statistics such as births or deaths; to report Suspected Abuse or Neglect to public authorities and to Correctional Institutions if you are in jail or prison, as necessary for your health and the health and safety of others.

For Law Enforcement Purposes such as when we receive a subpoena, court order, or other legal processes, or you are the victim of a crime. for Health and Safety Oversight Activities, we may share health information with the Department of Health. For Disaster Relief Purposes; we may share health information with disaster relief agencies to assist in the notification of your condition to family or others

In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order. For Specialized Government Functions. For example, we may share information for national security purposes. Other Uses and Disclosures of Protected Health Information and Additional Information. Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

We provide patients with the opportunity to communicate with us via electronic means (e-mail, fax, etc.). These communications are not encrypted. If you choose to communicate with us via e-mail please note that we cannot ensure the confidentiality of the information contained in e-mail messages. For example, most employers have access to employee email content so if you use your work email, your employer may be able to read the messages sent to/from our office.

We keep a record of the health care services we provide you. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting our office manager.

By my signature below I acknowledge that I have been offered a copy of the Notice of Privacy Practices. I understand that this notice is also available for review at _______________________

Print Patient Name Print Patient Social Security Number

Patient or legally authorized individual signature Date Time
__________________________________________________________ ____________________________________
Printed name if signed on behalf of the patient Relationship
(parent, legal guardian, personal representative)
A copy of this form will be retained in your medical record.