PRIVACY PRACTICES

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and our responsibilities.

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.
  • We will provide a copy or summary within 30 days of your request.
  • We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct information that is incorrect or incomplete.
  • We may deny your request, but we will tell you why in writing within 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (e.g., home phone, office phone) or send mail to a different address.
  • We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use/share certain health information for treatment, payment, or operations.
  • We are not always required to agree, and may say no if it affects your care.
  • If you pay out-of-pocket in full for a service, you can request it not be shared with your health insurer. We will agree unless the law requires otherwise.

Get a list of those with whom we’ve shared information

  • You can request an accounting of disclosures from the past six years.
  • We’ll provide one accounting per year for free; additional requests may have a reasonable fee.

Get a copy of this privacy notice

  • You can request a paper copy anytime, even if you agreed to receive it electronically.

Choose someone to act for you

  • If you have a medical power of attorney or legal guardian, that person can act for you.
  • We will verify their authority before taking action.

File a complaint if you feel your rights are violated

  • You can complain to us directly.
  • Or file a complaint with the U.S. Department of Health & Human Services at:
    200 Independence Ave SW, Washington, DC 20201
    1-877-696-6775
    www.hhs.gov/ocr/privacy/hipaa/complaints/
  • We will not retaliate against you.

Your Choices

For certain health information, you may tell us how you want it shared.

You may choose whether we:

  • Share information with family, friends, or others involved in your care
  • Share information in disaster-relief situations
  • Include your information in a hospital directory

If you are unable to express your preference (e.g., unconscious), we may share if it is in your best interest or necessary to reduce a serious threat.

We will not share your information without written permission for:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

Fundraising

  • We may contact you for fundraising, but you may opt out at any time.

Our Uses and Disclosures

Treat you

We may use/share your health information with professionals who are treating you.
Example: A doctor treating you for an injury consults another provider.

Run our organization

We may use/share your information to operate our practice, improve your care, and communicate with you.
Example: Managing your treatment and services.

Bill for your services

We may use/share information to bill and receive payment from insurers.
Example: Sending info to your health insurance plan.

Other Ways We May Use or Share Your Information

We may share your information in ways that contribute to the public good, following legal requirements.

Public health & safety

  • Preventing disease
  • Product recalls
  • Reporting adverse reactions
  • Reporting abuse, neglect, or domestic violence
  • Preventing or reducing serious threats to health/safety

Research

  • We may use/share information for health research.

Comply with the law

  • We must share information if federal or state laws require it.

Organ & tissue donation

  • We may share information with organ procurement organizations.

Medical examiner or funeral director

  • We may share information when an individual dies.

Workers’ compensation, law enforcement, and government

We may share information for:

  • Workers’ compensation claims
  • Law enforcement purposes
  • Health oversight activities
  • Special government functions (military, national security, protective services)

Lawsuits & legal actions

  • We may share information in response to a court order, subpoena, or administrative request.

Our Responsibilities

  • We must maintain the privacy and security of your protected health information.
  • We must notify you of any breach affecting your information.
  • We must follow the practices in this notice.
  • We will not use/share your information beyond what is described unless you provide written permission.
  • You may revoke permission at any time.

For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to This Notice

We may change this notice, and changes apply to all information we have.
The updated notice will be available upon request in our office.