Notice of Privacy Practices

• 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.

• 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.

• 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.

• 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.

• 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 this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

• 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.

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• 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.

• 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.

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

• We may contact you for fundraising efforts, but you can tell us not to
  contact you again.

• 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.

• 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.

• 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.

• 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: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

• 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 information for health research.

• 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.

• We can share health information about you with organ procurement
  organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

• We can share health information about you in response to a court or
  administrative order, or in response to a subpoena.

• 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