Your Information. Your Rights. Our Responsibilities.

This no ce describes how medical informa on about you may be used and disclosed and how you can get access to this informa on. Please review it carefully.

Your Rights

When it comes to your health information, you have certain rights. This sec on explains your rights and some of our responsibilies 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 informa on we have about you. Ask us how to do this.
  • We will provide a copy of a summary of your health informa on, 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 informa on 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 wri ng 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 or share

  • You can ask us not to use or share certain health informa on for treatment, payment, or our opera ons. 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 informa on for the purpose of payment or our opera ons with your health insurer. We will say “yes” unless a law requires us to share that informa on.

Get a list of those with whom we’ve shared information

  • You can ask for a list (accoun ng) of the mes we’ve shared your health informa on 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 opera ons, and certain other disclosures (such as any you asked us to make). We’ll provide one accoun ng a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

  • You can ask for a paper copy of this no ce at any me, even if you have agreed to receive the no ce electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

  • If you have given someone medical power of a orney or if someone is your legal guardian, that person can exercise your rights and make choices about your health informa on.
  • We will make sure the person has this authority and can act for you before we take any ac on.

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contac ng us using the informa on 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 vising www.hhs.gov/ocr/privacy/hipaa/complaints/.
  • We will not retaliate against you for filing a complaint.

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 informa on in the situa ons described below, talk to us. Tell us what you want us to do, and we will follow your instruc ons.
In these cases, you have both the right and choice to tell us to:

  • Share informa on with your family, close friends, or others involved in your care
  • Share informa on in a disaster relief situa on
  • Include your informa on 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.

Treat you

We can use your health informa on and share it with other professionals who are trea ng you.

Example: We will send a report on our consult to your healthcare provider and your baby’s

Run our organization

We can use and share your health informa on to run our prac ce, 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 informa on to bill and get payment from health plans or other en es.

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 informa on in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many condi ons in the law before we can share your informa on for these purposes. For more informa on see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health informa on about you for certain situa ons such as:

  • Preven ng disease
  • Helping with product recalls
  • Repor ng adverse reac ons to medica ons
  • Repor ng suspected abuse, neglect, or domes c violence
  • Preven ng or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your informa on for health research.

Comply with the law

We will share informa on 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.
Respond to organ and tissue donation requests
We can share health informa on about you with organ procurement organiza ons.

Work with a medical examiner or funeral director

We can share health informa on 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 informa on about you.

  • For workers’ compensa on claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for ac vi es authorized by law
  • For special government func ons such as military, na onal security, and presiden al protec ve services

Respond to lawsuits and legal actions

We can share health informa on about you in response to a court or administra ve order, or in response to a subpoena.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health informa on.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security ofyour informa on.
  • We must follow the du es and privacy prac ces described in this no ce and give you a copy of it.
  • We will not use or share your informa on other than as described here unless you tell us we can in wri ng. If you tell us we can, you may change your mind at any me. Let us know in wri ng if you change your mind.

For more informa on 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 no ce, and the changes will apply to all informa on we have about you. The new no ce will be available upon request, in our office, and on our web site.