PLEASE REVIEW CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain privacy of your health
information. We are also required to give you this notice about our privacy practices, our legal
duties and your rights concerning your health information.
We must follow the privacy practices
that are described in this notice while it is in effect. This notice took effect April 15,2021 and will
remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time,
provided such changes are permitted by applicable law. We reserve the right to make the changes
in our privacy practices and the new terms of our Notice effective for all health information that
we maintain, including health information we created or received before we made the changes.
Before we make a significant change in our privacy practices, we will change this Notice and
make a new Notice available upon request.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment and healthcare
operations, for example:
Treatment – We may use of disclose your health information to a physician or other healthcare
provider providing treatment to you.
Payment – We may use and disclose your health
information to obtain payment for services we provide you.
Healthcare Operations – We may use and disclose your health information in connection with
our healthcare operations. Healthcare operations include quality assessment and improvement
activities, reviewing the competence or qualifications of healthcare professionals, evaluating
practitioner and provider performance, conducting training programs, accreditation, certification,
licensing or credentialing activities.
Your Authorization – In addition to our use of your health information for treatment, payment or
healthcare operations, you may give us written authorization to use your health information or to
disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in
writing at any time. Your revocation will not affect any use or disclosures permitted by your
authorization while it was in effect. Unless you give us written authorization, we cannot use or
disclose your health information for any reason except those described in this Notice.
To your family and friends – We must disclose your health information to you, as described in
the Patient Rights section of this Notice. We may disclose your health information to a family
member, friend or other person to the extent necessary to help with your healthcare or with
payment for your healthcare but only if you agree that we may do so.
Persons Involved in Care – We may use or disclose health information to notify or assist in the
notification of (including identifying or locating) a family member, your personal representative
or another person responsible for your care, of your location, your general condition, or death, if
you are present, then prior to use or disclosure of your health information, we will provide you
with an opportunity to object to such uses or disclosures. In the event of your incapacity or
emergency circumstances we will disclose health information based on a determination using
your healthcare.
We will also use our professional judgment and our experience with common practice to make
reasonable inferences or your best interest in allowing a person to pick.
Marketing Health-Related Services - We will not use your health information for marketing
communications without your written authorization.
Required by Law – We may use or disclose your health information when we are required to do
so by law.
Abuse or Neglect – We may disclose your health information to appropriate authorities if we
reasonably believe that you are a possible victim or abuse, or neglect, or domestic violence or the
possible victim of other crimes. We may disclose your health information to the extent necessary
to avert a serious threat to your health or safety or the health of safety of others.
National Security – We disclose to military authorities the health information of Armed Forces
personnel under certain circumstances. We may disclose to authorize federal officials health
information required for lawful intelligence, counterintelligence, and other national security
activities. We may disclose to correction institution or law enforcement official having lawful
custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders – We may use or disclose your health information to provide you with
appointment reminders (such as voicemail messages, postcards, emails, letters, or text messages)
PATIENT RIGHTS
Access - You have the right to look at or get copies of your health
information, with limited exception. You may request that we provide copies in a format other
than photocopies. We will use the format you requested unless we cannot practically do so. (You
must make a 2 request in writing to obtain access to your health information.
You may obtain a form to request access by using the contact information listed at the end of the Notice.
We will charge you a reasonable cost-based fee for expenses such as copies and staff time.
You may also request access by sending us a letter to the address at the end of this Notice. If you
request copies, we will charge you for each page and per hour for staff time to locate and copy
your health information, and postage if you want to copies mailed to you.
If you request an alternate format, we will charge a cost-based fee for providing your health
information in that format. If you prefer, we will prepare a summary or an explanation of your
health information for a fee. Contact us using the information listed at the end of this Notice for a
full explanation of our fee structure.)
Disclosure Accounting – You have the right to receive a list of instances in which we or our
business associates disclosed your health information for purposes, other than treatment,
payment, healthcare operations and certain other activities, for the last 6 years, but not before
April 14th, 2003. If your request this accounting more than once in a 12-month period, we may
charge you a reasonable, cost-based fee for responding to these additional cost.
Restriction – You have the right to request that we place additional restrictions on our use or
disclosure of your health information. We are not required to agree to these additional
restrictions, but if we do, we will abide by our agreement (except in emergency.)
Alternate Communication – You have the right to request that we communicate with you about
your health information by alternative means or to alternate locations. You must make the request
in writing. Your request must specify the alternative means or location, and provide satisfactory
explanation how payments will be handled under the alternative means or location you request.
Amendment – You have the right to request that we amend your health information. (Your
request must be in writing, and it must explain why the information should be amended.) We
may deny your request under certain circumstances.
Electronic Notice – If you receive the Notice on our website or by electronic mail (e-mail), you
are entitled to receive this Notice in a written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have any questions or concerns,
please contact us. If you are concerned that we may have violated your privacy rights, or you
disagree with a decision we made about access to your health information or in response to a
request you made to amend or restrict the use or disclosure of your health information or to have
us communicate with you by alternative means or at alternative locations, you may complain to
us using the contact information listed at the end of this Notice.
You may also submit a written complain to the U.S. Department of Health and Human Services.
We will provide you with the address to file your complaint with the U.S. Department of Health
and Human Services upon request. We support yor right to the privacy of your health
information. We will not retaliate in any way if you chose to file a complaint with us or with the
U.S. Department of Health and Human Services.
Acknowledgment of Receipt of Notice of Privacy Practice
*You May Refuse to Sign This Acknowledgement*