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Updated 09/2022

This notice describes how medical information about you may be used, disclosed, and how you can get access to this information. Please review this document carefully. 

Patient Health Information (PHI)

Under federal law, your patient health information (PHI) is protected and confidential.  Patient health information (PHI) includes information about your symptoms, test results, diagnosis, treatment and related medical information. Your patient health information (PHI) also includes payment, billing and insurance information.  We are committed to protect the privacy of your PHI. 

How we use your patient health information (PHI)

This Notice of Privacy Practices (Notice) describes how we may use without our practice or network and disclose (share outside of our practice or network) your PHI to carry out treatment, payment or health care operations, for administrative purposes, for evaluation of the quality of care, and so forth. We may also share your PHI for other purposes that are permitted or required by law.  This Notice also describes your rights to access and control your PHI.  Under some circumstances we may be required to use or disclose your PHI without your consent.  

Treatment: We will use and disclose your PHI to provide you with medical treatment or services.  We may also disclose your PHI to other health care providers who are participating in your treatment, to pharmacist who are filling your prescriptions, to laboratories performing tests, and to family members who are helping with your care, and so forth. 

Payment: We will use and disclose your PHI for payment purposes.  For example, we may need to obtain authorization from your insurance company before providing certain types of treatment.  We will submit bills and maintain records of payments from your health plan.  PHI may be shared with the following: billing companies, insurance companies (health plans), government agencies in order to assist with qualifications of benefits, or collection agencies. 

Operation: We may ask you to complete a sign-in sheet or staff members may ask you the reason for your visit so we can better care for you.  Despite safeguards, it is always possible in a doctor’s office that you may learn information regarding other patients or they may inadvertently learn something about you.  In all cases, we expect and request that our patients maintain strict confidentiality of PHI. 

We may use or disclose your PHI to perform various routine functions (e.g. quality evaluations or records analysis, training students, other health care providers or ancillary staff such as billing personnel, to assist in resolving problems or complaints within the practice). We may use your PHI to contact you to provide information about referrals, for follow-up with lab results, to inquire about your health or for other reasons. We may share your PHI with Business Associates who assist us in performing routine operational functions, but we will always obtain assurance from them to protect your PHI the same as we do. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information.

Special Situations that DO NOT require your permission: We may be required by law to report gunshot wounds, suspected abuse or neglect, and so on; we may be required by law to disclose vital statistics, diseases and similar information to public health authorities; we may be required to disclose information for audits and similar activities, in response to a subpoena or court order, or as required by law enforcement officials. We may release information about you for worker’s compensation or similar programs to protect your health or the health of others or for legitimate government needs, for approved medical research, or to certain entities in the case of death. For example, to the extent your care is covered by workers' compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers' compensation insurer. Your PHI may also be shared if you are an inmate or under custody of law which is necessary for your health or the health and safety of other individuals.


Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel for activities deemed necessary by appropriate military command authorities, for the purpose of a determination by the Department of Veteran’s Affairs of your eligibility for benefits or to foreign military authority if you are a member of that foreign military services.  

In some situations, we may ask for your written authorization before using or disclosing any identifiable health information about you. If you sign an authorization, you can later revoke the authorization.  

Individual Rights

You have certain rights with regard to your PHI, for example:

Unless you object, we may share your PHI with friends or family members, or other persons directly identified by you at the level they are involved in your care or payment of services.  If you are not present or able to agree/object, the health provider using profession judgement will determine if it is in your best interest to share the information.  We may use or disclose PHI to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition or death.  We may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts.


You may request restriction on certain uses and disclosures of your PHI.  We are not required to accept all restrictions.  If you pay in full for a treatment or service immediately, you can request that we not share this information with your medical insurance provider or our Business Associates.  We will make every attempt to accommodate this request and, if we cannot, we will tell you prior to treatment.  

You may ask us to communicate with you confidentially by, for example, sending notices to a special address.  

In most cases, you have the right to get a copy of your PHI.  There may be a charge for the copies. We will charge a reasonable fee which covers our costs for labor, supplies, postage

You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.

Our Legal Duty

We are required by law to protect and maintain the privacy or your PHI, to provide this Notice about our legal duties and privacy practices regarding PHI, and to abide by the terms of the Notice currently in effect.  We may update or change our privacy practices, and policies at any time.  Before we make a significant change in our policies, we will change our Notice and post the new Notice in the admissions.  You can also request a copy of our Notice at any time.  

If you are concerned about your privacy rights, or if you disagree with the decision we make about your records, you may contact the Privacy Officer listed below.  You may also send a written complain to the U.S. Department of Health and Human Services.  You will not be penalized in any way for filing a complaint.  

Contact Person

If you have any questions, or complaints, please contact:

The Spine Institute   
Attn:  Privacy Officer    

5911 S. Fashion Blvd.

Murray, UT  84107



I acknowledge that I received a copy of The Spine Institute,” Notice of Privacy Practices” to review.  I understand that if I would like a copy of this notice, The Spine Institute will provide me with a copy of this documentation.   




Centralized Case Management  Operations 

U.S. Department of Health and Human Services

200 Independence Avenue

Room 509F HHH Bldg.

Washington, D.C. 20201 

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