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.
Your Rights
When it comes to your health information, you have
certain rights. This section explains your rights and some
of our responsibilities to help you. You can get an
electronic or paper copy of your medical record:
ASK US TO CORRECT YOUR MEDICAL RECORD
REQUEST CONFIDENTIAL COMMUNICATIONS
ASK US TO LIMIT WHAT WE USE OR SHARE
GET A LIST OF THOSE WITH WHOM WE’VE SHARED
INFORMATION
GET A COPY OF THIS PRIVACY NOTICE
CHOOSE SOMEONE TO ACT FOR YOU
FILE A COMPLAINT IF YOU FEEL YOUR RIGHTS ARE
VIOLATED
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 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:
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:
In the case of fundraising:
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 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:
www.hhs.gov/ocr/privacy/hipaa/understanding/consum
ers/index.html
HELP WITH PUBLIC HEALTH AND SAFETY ISSUES
We can share health information about you for certain
situations such as:
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
We can share health information about you with organ
procurement organizations.
WORK WITH A MEDICAL EXAMINER OR FUNERAL
DIRECTOR
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
We can use or share health information about you:
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.
Our Responsibilities
FOR MORE INFORMATION SEE:
www.hhs.gov/ocr/privacy/hipaa/understanding/consum
ers/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, in our office, and on
our website.