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.
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.
As 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
- 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 say “yes” to all reasonable requests.
Ask us to limit what we use
- 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 make). We’ll provide one accounting a
year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
- You can ask for a paper copy of 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.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on the back page.
- We may charge a reasonable, cost-based fee. 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, SW Washington DC 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
- We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what
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 care
- Share information in a disaster relief situation
- Include your information in a hospital directory
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
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of 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
- We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our Organization
- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your Services
- We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
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:
Help with public health and safety issues?
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
- We can use or share your inforamtion for health research
Comply 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 procurement organizations
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- 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.
For more information see:
Super-Confidential Information Rule
If we have PHI about you regarding comminicable diseases, disease test, alcohol or substance abuse diagnosis and treatment, or psychotherapy and mental health records ( super-confidential information under the law ), we will not disclose it under the General or Healthcare Treatment, Payment or Operations Rules without you first signing and properly completing our Consent Form (i.e. you specifically must initial the type of super-confidential information we are allowed to disclose ).
If you do not specifically authorize disclosure by initializing the super-confidential information, we will not disclose it unless authorized under the Special Rules (see above) (i.e. we are required by law to disclose)
If we disclose super-confidential information, (either because you have initialed the consent form or the Special Rules authorizing us to do so), we will comply with State and Federal Law that requires us to warn the recipient in writing that re-disclosure is prohibited.
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 web site.
This Notice of Privacy Practices applies to the following organizations.