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.
Effective Date: June 22, 2015
When it comes to your health information, you have certain rights. This explains your rights and our responsibilities.
Get an electronic or paper copy of your medical record.
- You can ask to see or obtain an electronic or paper copy of your medical record. Ask us how to do this.
- We will permit inspection of your medical record within 5 working days after receiving your written request. We will provide a copy or a summary of your health information no more than 15 working days after receiving your written 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.
- 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 (such as 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 it.
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. 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 violated your rights by contacting us using the information at the top of the form.
- 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.
- 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 if you so request.
- 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 on our web site. Upon request, we will give or mail a copy to you.
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
In the case of fundraising:
- We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our uses and disclosures
How do we typically use or share your health information? We typically use or share it 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, 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
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
- 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 to respond to a court or administrative order, or to respond to a subpoena.
- We may use and release information about you for the purposes of legal cases in which our services are rendered for the purposes of providing an expert opinion. In response to a court or administrative order, we may be required to disclose information about you. We may also disclose information about you in response to a subpoena, discovery request, or other lawful process by another party involved in a legal dispute.