NOTICE OF PRIVACY PRACTICES
Effective date of notice: September 2018
|THIS NOTICE DESCRIBES HOW
MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
GET ACCESSTO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We respect our legal obligation to keep health information that
identifies you private. We are obligated by law to give you notice of
our privacy practices. This notice describes how we protect your health
information and what rights you have regarding it.
|When it comes to your health
information, you have certain rights. This section explains your rights
and some of our responsibilities to help you.
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. Ask us how to do this. We will provide a
copy or a summary of your health information, usually 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 health
information about you that you think is incorrect or incomplete. Ask us
how to do this. We may say “no” to your request, but we’ll tell you why
in writing within 60 days.
Request confidential communications.
can ask us to contact you in a specific way (for example, home or office
phone) or to send mail to a different address. We will say “yes” to all
Ask us to limit what we use or share. You can
ask us not to use or share certain health information for treatment,
payment, or our operations. We are not required to agree to your
request, and we may say “no” if it would affect your care. If you pay
for a service or health care item out-of-pocket in full, you can ask us
not to share that information for the purpose of payment or our
operations with your health insurer. We will say “yes” unless a law
requires us to share that information.
Get a list of those with whom
we’ve shared information. You can ask for a list (accounting) of the
times we’ve shared your health information for six years prior to the
date you ask, who we shared it with, and why. We will include all the
disclosures except for those about treatment, payment, and health care
operations, and certain other disclosures (such as any you asked us to
Get a copy of this privacy notice. You
can ask for a paper copy of this notice at any time, even if you have
agreed to receive the notice electronically. We will provide you with a
paper copy promptly
Choose someone to act for you. If you have given someone medical power
of attorney or if someone is your legal guardian, that person can
exercise your rights and make choices about your health information.
File a complaint if you feel your rights are violated. You can complain
if you feel we have violated your rights by contacting us at the number
listed above. You can file a complaint with the U.S. Department of
Health and Human Services Office for Civil Rights by sending a letter to
200 Independence Avenue, S.W., Washington, D.C. 20201, calling
1-877-696-6775, or visiting
We will not retaliate against you for filing a complaint.
health information, you can tell us your choices about what we share.
If you have a clear preference for how we share your information in the
situations described below, talk to us. Tell us what you want us to do,
and we will follow your instructions. In these cases, you have both the
right and choice to tell us to:
|1) Share information
with your family, close friends, or others involved in your
2) Share information in a disaster relief situation.
3) Include your information in a hospital directory.
you are not able to tell us your preference, for example if you are
unconscious, we may go ahead and share your information if we believe it
is in your best interest. We may also share your information when needed
to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us
2) Sale of your information.
3) Fundraising - We
may contact you for fundraising efforts, but you can tell us not
to contact you again.
OUR USES AND DISCLOSURES
|How do we typically use or share
your health information? We typically use or share your health
information in the following ways. 1) Treat you. We can use your health
information and share it with other professionals who are treating you.
2) Run our organization. We can use and share your health information to
run our practice, improve your care, and contact you when necessary. 3)
Bill for your services. We can use and share your health information to
bill and get payment from health plans or other entities.
We are allowed or required to share your information in other
ways - usually in ways that contribute to the public good, such
as public health and research. We have to meet many conditions in the
law before we can share your information for these purposes.
Help with public health and safety issues. We can
share health information about you for certain situations such as: 1)
Preventing disease. 2) Helping with product recalls. 3) Reporting
adverse reactions to medications. 4) Reporting suspected abuse, neglect,
or domestic violence. 5) Preventing or reducing a serious threat to
anyone’s health or safety.
Do research. We can
use or share your information for health research.
with the law. We will share information about you if state or
federal laws require it, including with the Department of Health and
Human Services if it wants to see that we’re complying with federal
Respond to organ and tissue donation
requests. We can share health information about you with organ
Work with a medical examiner
or funeral director. We can share health information with a
coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other
government requests. We can use or share health information
|1) For workers’
2) For law enforcement purposes or with
a law enforcement official.
3) With health oversight agencies
for activities authorized by law
4) For special government
functions such as military, national security, and presidential
Respond to lawsuits and legal actions. We can share health information about you in response
to a court or administrative order, or in response to a subpoena.
|1) We are required by
law to maintain the privacy and security of your protected health
2) We will let you know promptly if
a breach occurs that may have compromised the privacy or security of
3) We must follow the duties and
privacy practices described in this notice and give you a copy of it.
4) We will not use or share your information other than
as described here unless you tell us we can in writing. If you tell us
we can, you may change your mind at any time. Let us know in writing if
you change your mind.
5) For more information see:
6) Changes to the Terms of this Notice.
|We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you.
OUR NOTICE OF PRIVACY PRACTICES
|By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new one in our office and have copies available in our office.
|If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax, or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, please call or
visit one of our offices.