PRIVACY PRACTICES

Your Information.

Your Rights.

Our Responsibilities.

Your Choices.

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When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

 

Your Rights

Get an electronic or paper copy of your medical record

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• 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.

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• 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.

 

Ask us to correct your medical record

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• You can ask us to correct health information about you that you think is incorrect

or incomplete. Ask us how to do this.

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• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

 

Request confidential communications

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• 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.

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Ask us to limit what we use or share

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• 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.

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• 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

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• 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.

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• We will include all the disclosures except those about treatment, payment, 

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 charge a reasonable,

cost-based fee if you ask for another within 12 months.

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 electronically. We will promptly provide you with a paper copy.

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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.

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File a complaint if you feel your rights are violated

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• 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.

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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

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For certain health information, you can tell us your choices about what we share. Talk to us if you have a clear preference for how we share your information in the situations described below. Tell us what you want us to do, and we will follow your instructions.

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Your Choices

Treat you•

• 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.

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Run our organization

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• 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.

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Bill for your services

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• 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.

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How do we typically use or share your health information?

We typically use or share your health information in the following ways.

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Our Uses and Disclosures

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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

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Do research • We can use or share your information 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 privacy law.

Respond to organ and tissue donation requests

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We can share your health information with organ procurement organizations.

Work with a medical examiner or funeral director

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We can share health information with a coroner, medical examiner, or funeral

director when an individual dies.

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

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• 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

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

presidential protective services

Respond to lawsuits and

legal actions

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We can share health information about you in response to a court or

administrative order, or in response to a subpoena.