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.
Our commitment to your privacy
Our practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. We are also required by law to keep your information private. This document is a shorter version of the full, legally required notice of privacy practices which is available at:
Please talk to our privacy officer (see the end of this form) about any questions or problems.
How we use and disclose your protected health information with your consent
We will use the information collected about you mainly to provide you with treatment, to help you arrange payment for services, and for some other business activities that are called, in the law, health care operations. After you have read this notice (at or before your intake appointment) we will ask you to sign a consent form to let us use and share your information in these ways. If you do not consent and sign this form, we cannot treat you. If we want to use or send, share, or release your information for other purposes, we will discuss this with you and ask you to sign an authorization form to allow this.
Disclosing your health information without your consent
There are some times when the laws require us to use or share your information. For example:
- When there is a serious threat to your or another’s health and safety or to the public. We will only share information with persons who are able to help prevent or reduce the threat.
- If you report abuse of a member of the vulnerable population (e.g. minors, handicapped person, prenatal abuse, or elder abuse)
- When we are required to do so by lawsuits and other legal or court proceedings.
- If a law enforcement official requires us to do so.
There are some other rare situations. They are described in the longer version of the notice of privacy practices referenced above.
Your rights regarding your health information
- You can ask us to communicate with you in a particular way or at a certain place that is more private for you. For example, you can ask us to call you at home, and not at work, to schedule or cancel an appointment. We will try our best to do as you ask.
- You can ask us to limit what we tell people involved in your care or the payment for your care, such as family members.
- You have the right to look at the health information we have about you, such as your medical and billing records. You can get a copy of these records, but we may charge you for the cost of materials. Contact the privacy officer (see below) to arrange how to see your records.
- If you believe that the information in your records is incorrect or missing something important, you can ask us to make additions to your records to correct the situation. You have to make this request in writing and send it to the privacy officer (below). You must also tell us the reasons you want to make the changes.
- You have the right to a copy of this notice. If we change this notice, we will post the new version in the patient portal, and you can always get a copy of it from the privacy officer.
- You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with the privacy officer and with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way. Also, you may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. We will be happy to discuss these situations with you now or as they arise.
If you have any questions regarding this notice or our health information privacy policies, please contact the privacy officer, who is Esther Davis and can be reached by e-mail at firstname.lastname@example.org.
The effective date of this notice is April 1, 2021.