HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices

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 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.

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 not be able to grant 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.
• 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) or 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.

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.

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 for 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 serios and imminent threat to
  health or safety.

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 tour information for these purposes.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/cosumers/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 suspect 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 laws.

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.
• or 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.

Reproductive Rights

We protect the privacy of reproductive health information. We do not use or disclose
such information for investigations or legal actions related to lawful reproductive health
care. Disclosures in response to legal requests require a valid attestation as required by
federal law.

Substance Use Disorder (S.U.D)

Substance Use Disorder (SUD) records receive special protection under federal law. We
generally need your written consent to share this information, except in limited situations
allowed by law, such as medical emergencies or court orders.

Our Responsibilities

• We’re 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

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.

I hereby acknowledge that I have received a copy of this office’s Notice of Privacy Practices. I
may refuse to sign this acknowledgement. To obtain a paper copy I may request it from the
office.

Print First, Last Name:__________________________________________________________

Signature:_______________________________________________
Date:________________