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

 

You have the right to:

 

Get a copy of your paper or electronic 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.

 

Correct your paper or electronic 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 within 60 days.

 

Request confidential communication

• 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 the information we 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.

 

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 believe your privacy rights have been violated

• You can complain if you feel we have violated your rights by contacting us.

• 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 www.hhs.gov/ocr/ privacy/hipaa/complaints.

• We will not retaliate against you for filing a complaint.

 

We may use and share your information as we:

 

Provide services to you

• We can use your health information and share it with other professionals who are treating you.

 

Run our organization

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.

 

Bill for your services

• We can use and share your health information to bill and get payment from health plans or other entities.

 

Help with public health and safety issues

•  We can share health information about you for certain situations such as:

• Preventing disease

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

 

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 privacy law.

 

Work with a medical examiner or funeral director when someone dies

 

Address workers’ compensation, law enforcement, and other government requests

• We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

 

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.

 

We do not do the following:

 

• We will never contact you for fundraising efforts.

• We do not maintain a client directory

• Sell your personal information

 

Our Responsibilities

 

• 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: 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 and in our office.