Notice of Privacy Practices and Patient Rights as required by the Health Insurance Portability and Accountability Act (HIPAA)
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Federal and state law requires us to maintain the privacy of your health information. That law also requires us to inform you of our privacy practices, our legal duties, and your rights concerning your health information.
Protected Health Information (PHI) includes any information that describes the health problems or symptoms for which you are being treated, in conjunction with any personal identifying information about you.
Information pertaining to your treatment and the condition for which you are seeking treatment will not be disclosed to any entity or individual without your written authorization, with the following exceptions:
Healthcare professionals have a duty to protect. In the event your practitioner or identified representative determines that you are at risk of severe harm to yourself or another individual, that practitioner or identified representative is obligated to contact any appropriate individual, including law enforcement, to protect you or other identified individuals from harm.
Healthcare professionals have a duty to warn. In the event your practitioner or identified representative determines that you are at risk for causing severe harm to another individual, that practitioner or identified representative is obligated to contact any appropriate individual, including the potential victim(s) as well as law enforcement, to warn that individual(s) of their potential of harm.
Healthcare professionals have a duty to inform the proper authorities regarding any disclosure of information pertaining to the harm of a child or individual who is not legally, mentally, or physically able to act on their own behalf to protect themselves from this harm.
Your health information may be disclosed in order to coordinate your treatment with other health care providers who are participating in your healthcare treatment.
Your health information may be disclosed as necessary to obtain payment for services that are provided to you.
Your health information may be disclosed to provide you with appointment reminders (such as email or voicemail messages).
In the event of an emergency, information about you may be disclosed to a family member or other appropriate person involved in your care.
As required by law via court order. Your healthcare provider will take all reasonable precautions to
protect the confidentiality of your health information.
You have the right to look at or get copies of your health information. You must make a request in writing to obtain access to this information. Your provider reserves the right to charge a reasonable fee for this service to cover postage, copying, or other related expense.
You have a right to receive a list of instances in which your healthcare information was disclosed over the last six years, but not prior to 4/14/2003. This list will not include disclosures pertaining to treatment, appointment reminders, payment, and healthcare operations as authorized by you. Your provider reserves the right to charge a reasonable fee for this service to cover postage, copying, or other related expense.
You have the right to request that your provider communicate with you by alternative means or locations. You must make this request in writing and specify the alternate means and location, including how you will pay for this alternate communication if additional costs are incurred by your provider.
You have the right to request that your provider amend your health information. Your request must be in writing and must explain why s/he should amend the information. S/He may deny your request under certain circumstances.
You have a right to file a complaint with the U.S. Department of Health and Human Services, without retaliation, if you believe your provider has violated the privacy of your PHI.
Questions and Complaints
You may contact your provider using the information contained below if:
You want more information regarding your privacy rights.
You believe your rights have been violated.
You believe your provider has made an incorrect decision about access to your health information.
You believe your provider’s response to a request pertaining to your health information was incorrect.
You want your provider to communicate with you by alternate means or location.
You have any questions or complaints pertaining to your care or the privacy of your health information.