Consent/Privacy Notice/Disclosures

TX Orthobiologics Consent/Privacy/Disclosures

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Patient Consent/ Patient Privacy Notice

I understand that as part of the provision of healthcare services, Texas Orthobiologics creates and maintains health records and other information describing among other things, my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.

I have been provided with a Notice of Privacy Practices that provides more complete descriptions of uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their Notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations (quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical review, legal services and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested.

By signing or typing my name on this form, I consent to the use and disclosure of protected health information about me for the purposes of treatment, payment and health care operations. I have the right to revoke this consent, in writing, except where disclosures have already made in reliance on my prior consent.

This consent is given freely with the understanding that:

  1. Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment or health care operations without my prior authorization, except as otherwise provided by law.
  2. A photocopy or fax of this consent is as valid as the original.
  3. I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purposes of treatment, payment or health care operations be restricted. I also understand that the Practice and I must: agree to any restrictions by signing or typing my name on this form that I request on the use and disclosure of my Protected Health Information; and agree to terminate any restrictions in writing on the use and disclosure of my Protected Health Information; and agree to terminate any restrictions by signing or typing my name on this form on the use and disclosure of my Protected Health Information which have been previously agreed upon.
  4. I give consent to be contacted by mobile phone or email to verify my account information, payment information, or account balance.

By signing or typing my name in the space below, I am confirming that I have read and understood this document.

Texas Orthobiologics Disclosures

All physicians associated with Texas Orthobiologics are required by Texas law (SB 872, 2005) to disclose any ownership or financial interest in any health care facilities where our patients may receive care. We respect the rights of our patients to choose not only their surgeon but also where they wish to have any medical services provided for them.

Physicians in our practice have ownership in SurgCenter of Greater Dallas which is a private, state of the art surgery center.

We have taken these measures to ensure the quality of the medical care that we provide our patients.
We encourage our patients to discuss any concerns they have with us at the time of their office visit.

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