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.
Effective January 1, 2014
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:
- Treating You: We can use your health information and share it with other professionals who are treating For example, a doctor treating you for an injury asks another doctor about your overall health condition.
- Running Our Organization: We can use and share your health information to run our practice, improve your care and contact you when necessary. For example, we use health information about you to manage your treatment and
- Billing for Your Services: We can use and share your health information to bill and get payment from health plans or other entities. For example, we give information about you to your health insurance plan so it will pay for your
How else can we use or share your health information?
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. For more information, see: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
- Helping with Public Health and Safety Issues: We can share health information about you for certain situations such as:
- Helping with product
- Reporting adverse reactions to
- Reporting suspected abuse, neglect or domestic
- Preventing or reducing a serious threat to anyone’s health or
- Doing Research: We can use or share your information for health
- Complying 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 privacy
- Responding to Organ and Tissue Donation Requests: We can share health information about you with organ procurement organizations.
- Working with a Medical Examiner or Funeral Director: We can share health information with a coroner, medical examiner or funeral director when an individual
- Addressing Workers’ Compensation, Law Enforcement and Other Government Requests: We can use or share health information about you:
- For workers’ compensation
- For law enforcement purposes or with a law enforcement
- With health oversight agencies for activities authorized by
- For special government functions such as military, national security and presidential protective
- Responding 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
Your Rights – When it comes to your health information, you have certain rights.
This section explains your rights and some of our responsibilities to help you.
- Getting 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 Ask us how to do this. We will provide a copy or summary of your health information, usually within four business days of your request. We may charge a reasonable, cost-based fee.
- Asking 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 We may deny your request, but we’ll tell you why in writing within 60 days.
- Request Confidential Communications: You 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 approve all reasonable requests.
- 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 We are not required to agree to your request and may deny it if it affects your care.
- 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 We will provide you with a paper copy promptly.
- Choose Someone Else 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. We will make sure the person has this authority and can act for you before we take any
- File a Complaint if You Feel Your Rights Are Violated: If you feel we have violated your rights, you may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence SW Washington, DC 20201, by calling 1-877-696-6775 or by visiting: http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html
Your Choices – For certain 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:
- Share information with your family, close friends or others involved in your
- Share information in a disaster relief
- Include your information in a hospital
If 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 Written Permission:
- Sale of your
- Most sharing of psychotherapy
- In the Case of Fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you
- We are required by law to maintain the privacy and security of your protected health
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your
- We must follow the duties and privacy practices described in this notice and provide you with a
- We will not use or share your information other than as described here unless you give us permission in writing. If you allow this, you may change your mind at any time. Let us know in writing if you change your
For more information, see: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the Terms of This Notice
We can change the terms of this notice and the changes will apply to all information we have about you. The new notice will be available upon request, in our office and on our website.