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HIPAA Notice of Privacy Practices


Burning Tree Programs and all its associates at all locations value you as a patient and respects your right to privacy. We pledge our commitment to treating your information responsibly. We restrict access to your health information to only those employees who need to know in order to provide appropriate treatment or services to you or to conduct Burning Tree Program’s business on your behalf.

This Notice describes the rights you have concerning your own protected health information. This statement is effective on 9/23/2013 and complies with the Omnibus HIPAA Final Rule published January 25, 2013. We are required to abide by the terms of this Notice of Privacy Practices.


The following categories describe different ways that we use and disclose protected health information about you. Treatment: We may use or disclose your protected health information for your treatment, such as to a doctor or other healthcare provider providing treatment to you.

Your Authorization: You may give us written authorization or release to use your protected health information for any purpose that you deem necessary. You may revoke an authorization or release at any time; the revocation must be in writing. Your revocation will not affect any use or disclosures permitted by your release while it was in effect.

Individuals Involved in Your Care or Payment for Care: We may disclose your protected health information with your signed authorization to a family member, friend or other person to help with your healthcare.

Disaster Relief: We may disclose your protected health information to disaster relief organizations that seek your protected health information to coordinate your care, or notify or help locate a family member or friend in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever practical to do so.

Payment: We may use and disclose your protected health information so that we may be paid for the services and supplies we provide to you. For example, your health insurance company may request to see parts of your medical record before they will pay us for your treatment.

Marketing: We will not use your protected health-related information for marketing purposes. We will not sell your protected health information. Research: We do not disclose protected health information for research purposes without your written consent. Information without patient-identifiable data may be used for generic research.

Workers’ Compensation and Disability: With your signed release, protected health information about you may be disclosed for workers’ compensation, disability or similar programs.

The following categories describe different ways that we may use and disclose protected health information about you without a signed release. Required by Law: Federal, state, or local law may require us to disclose your protected health information.

Law Enforcement: We may release protected health information if asked by a law enforcement official if the information is (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Public Health: We may disclose protected health information about you for public health activities such as to prevent or control disease, injury or disability; to report reactions to medications, food, or problems with products; to authority authorized by law to receive reports of child abuse or neglect.

Health Care Operations: We may use and disclose your protected health information in connection with our health care operations. These uses and disclosures are necessary to run Burning Tree Programs and to make sure all of our patients receive quality care. Health care operations may also include, but are not limited to, accreditation and licensing, and conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers. We may use your information to provide information on services that may be of interest to you.

Coroners, Medical Examiners, and Funeral Directors: We may disclose protected health information to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law. We may disclose protected health information to funeral directors, consistent with applicable law, as necessary to carry out their duties. RMdoc118_Notice of Privacy Practices, 10/17/16

Organ, Eye, Tissue Donation: We may disclose protected health information to organizations that procure, bank or transplant organs or tissues. Health Oversight Activities: We may disclose protected health information to a health oversight agency for activities authorized by law. Military and Veterans: If you are a member of the armed forces, we may release your protected health information as required by military command authorities. We also may release Protected Health Information to the appropriate foreign military authority if you are a member of a foreign military.

National Security and Intelligence Activities: We may release protected health information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

To Avert a Serious Threat to Health or Safety: We may use and disclose protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Judicial and Administrative Proceedings: We may disclose protected health information in response to a court order or administrative tribunal order, a subpoena, a discovery request, or other lawful process but only when we have followed procedures required by law.

Victim of Abuse, Neglect, or Domestic Violence: We may use or disclose your protected health information to an authorized government authority, including a social service or protected services agency if we reasonably believe you to be a victim of abuse, neglect, or domestic violence. Data Breach Notification Purposes: We may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclosure of your health information.

Business Associates: We may disclose protected health information to our “business associates” who perform certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to us. All of our business associates are obligated to protect the privacy of protected health information and may use the information only for the purposes for which the business associate was engaged.

Secretary of Health and Human Services. We are required to disclose your information to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA Privacy Rules.

Other Uses and Disclosures: Other uses and disclosures of protected health information not covered by this Notice or the laws that apply to us will be made only with your written authorization.


Right to Access: You have the right to request to inspect and/or get copies of your own protected health information for as long as we maintain it, as required by law. You must submit your request in writing to the Privacy Official. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, staff time or other supplies associated with your request. We may deny your request to inspect and copy in certain circumstances. If you are denied access to protected health information, you may request that the denial be reviewed. Another licensed health care professional chosen by Burning Tree Programs will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records: If your protected health information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity.

Notification of a Breach: You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of any of your unsecured protected health information.

Right to Amend: You have the right to request that we amend your protected health information if you feel the information is wrong or incomplete. To request an amendment, your request must be made writing explaining why the information should be amended and submitted to our Privacy Official. We may deny your request under certain circumstances.

Right to Request Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your protected health information. We are not required to agree to any restriction that you may request. If we do agree to the restriction, we will comply with that restriction unless the information is needed to provide emergency treatment to you or unless the use or disclosure is otherwise permitted by law.

Right to an Accounting of Disclosures: You have the right to request a list of instances in which we disclosure your protected health information during the last 6 years. If you request this accounting more than once in a 12 month period we may charge you a reasonable, cost-based fee for responding to these additional requests.

Out-of-Pocket Payments: If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to request in writing that your protected health information with respect to that item or service not be disclosed to a health plan for purposes of payment or healthcare operations, and we will honor that request.

Right to Request Confidential Communications: You have the right to request that we communicate with you about your protected health information by alternative means or alternative locations. Your request must be made in writing and must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you requested.

Right to a Paper Copy: If you have received this Notice electronically, you have the right to a paper copy at any time. You may download a paper copy of this Notice from our website, at, or from our Privacy Official.


We reserve the right to change this Notice and to make the provisions in our new Notice effective for all protected health information we maintain, provided such changes are permitted or required by applicable law. If we change these practices, we will publish a revised Notice of Privacy Practices and make it available to you.


If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made regarding your health information, you may express your written complaint to us or the U.S. Department of Health & Human Services at the address below.

Our Privacy Official’s contact information is listed below. If you want more information about our privacy policy or have questions or concerns, please contact us. Our Compliance Official can be contacted at:

Burning Tree
Privacy Official
2837 Co Rd 101
Kaufman, TX 75142

U.S. Department of Health & Human Services

If you would like to submit a complaint directly to the U.S. Department of Health & Human Services please send it to the following address:

U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201

We support your right to privacy of your protected health information. You will not be retaliated against in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.