Notice of Privacy Practices

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.

 

When it comes to your health information, you have certain rights.

This section explains your rights and some of my responsibilities to help you.
You have a right to:

Get an electronic or paper copy
of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask me how to do this.

I will provide a copy or a summary of your health information, usually within 30 days of your request. I may charge a reasonable, cost-based fee.

 

Ask me to correct your medical record

 

Request confidential communications

 

You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this.

I may say “no” to your request, but I will tell you why in writing within 60 days.

 

You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

I will say “yes” to all reasonable requests.

 

Ask me to limit what I use or share

 

 

You can ask me not to use or share certain health

information for treatment, payment, or our operations.

I am not required to agree to your request, and I 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 me not to share that information for the purpose of payment or my operations with your health insurer.

I will say “yes” unless a law requires me to share that information.

 

Get a list of those with whom I have shared information

 

You can ask for a list (accounting) of the times I have shared your health information for six years prior to the date you ask, who I shared it with, and why.

I 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). I will 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. I 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.

I will make sure the person has this authority and can act for you before I take any action.

 

File a complaint if you feel your rights are violated

 

You can complain if you feel I have violated your rights by contacting me.

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/.

 

I will not retaliate against you for filing a complaint.