Legal Information

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.  

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 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.  
• If you request an electronic copy, we will provide the information in the electronic form and  format you requested, if it is readily producible. If it is not readily producible, we will work  with you to agree on a readable electronic format.

Ask us to correct your 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 in writing 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 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. o We will say “yes” unless a law requires us to share that information.

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

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 provide you with a paper copy promptly. 

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 feel your rights are violated 

• 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. 

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: 

• 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  
• Contact you for fundraising efforts 

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 

Fundraising Communications: 

• We may contact you for fundraising efforts, but you have the right to opt out of fundraising  communications at any time.
• You may opt out by following the instructions included in any fundraising  communication, or by contacting us via the information listed at the top of page 1 of  this notice.

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/consumers/index.html. 

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

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:
  • 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. 

Special Protections for Substance Use Disorder Records (42 CFR Part 2) 

• If we provide substance use disorder (SUD) diagnosis, treatment, or referral for  treatment and are subject to 42 CFR Part 2, your SUD records receive additional  protections under federal law. 
• In general, we may not use or disclose these records unless you provide written  consent or unless otherwise permitted by law. 
• Under federal law, you may authorize a single written consent for the use and  disclosure of your SUD records for treatment, payment, and health care operations.  This consent remains valid until you revoke it in writing.
• Certain disclosures — such as for law enforcement investigations, legal  proceedings, or the disclosure of counseling notes — require separate, specific consent unless otherwise permitted by law. 
• If a breach of your SUD records occurs, we will notify you as required by law. 

Note: These additional protections apply only to records covered by 42 CFR Part 2. Not all  health information is subject to these rules. 

1. We do not create/maintain a hospital directory at this practice. 
2. We do not create/maintain psychotherapy notes at this practice. 
3. We do not create/maintain Substance Use Disorder records at this practice. 

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.