Effective Date: [06/2024]

Your Information. Your Rights. Our Responsibilities.

This Privacy Policy outlines how your personal information may be used and disclosed, and how you can access this information. Please review it carefully.

Contact Information:

For additional information or to file a complaint regarding your privacy rights, you may contact our Compliance Officer or the Department of Health and Human Services Office for Civil Rights.

Our Uses and Disclosures

Protected Health Information (PHI): PHI is any information created or received by a healthcare provider that relates to your past, present, or future physical or mental health or condition, to the provision of health care to you, or to payment for your health care.

Typical Uses and Disclosures: We may use or disclose your PHI without your consent or authorization for the following purposes:

• Treatment: We may use and share your health information with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
• Payment: We may use and share your health information to bill and get payment from health plans or other entities. Example: We provide information about you to your health insurance plan so it will pay for your services.
• Health Care Operations: We may use and share your health information to run our practice, improve your care, and contact you when necessary. Example: Quality assessment audits and improvement activities.

Business Associates: Some services are provided through business contracts. When these services are contracted, we may disclose your PHI to our business associate so they can perform the job we have asked them to do. To protect your health information, we require the business associate to appropriately safeguard your PHI.

Patient Satisfaction and Reviews: We may contact and survey you via email regarding your satisfaction and outcomes. An independent vendor may assist with data collection. This office or a designated vendor may also send an automated email to allow you to rate and review your provider online through sites like Google, Yelp, etc. These reviews are optional, and you should not include sensitive, personal, identifying, or medical information that you do not wish to be publicly disclosed.

Our Responsibilities:

• We are required by law to maintain the privacy and security of your PHI.
• We will notify you 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.
• 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 by submitting a written revocation.

Your Choices:

For certain health information, you can tell us your preferences on what we share. If you have a clear preference for how we share your information in the situations described below, please let us know, and we will follow your instructions:

• Share information with your family, close friends, or others involved in your care.
• Share information in a disaster relief situation.
• Contact you for fundraising efforts, but you can tell us not to contact you again.

Other Uses and Disclosures:

We are required to share your information in other ways that usually contribute to the public good, such as public health and research. We must meet many conditions in the law before we can share your information for these purposes. Examples include:

• Public Health and Safety: Preventing disease, reporting adverse reactions to medications, reporting suspected abuse or neglect, and preventing or reducing a serious threat to anyone’s health or safety.
• Research: We can use or share your information for health research.
• Compliance with Law: We will share information about you if state or federal laws require it.
• Organ and Tissue Donation Requests: We can share health information about you with organ procurement organizations.
• Medical Examiner or Funeral Director: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• Workers’ Compensation, Law Enforcement, and Government Requests: We can use or share health information about you for workers’ compensation claims, law enforcement purposes, and health oversight activities.
• Responding to Lawsuits and Legal Actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Your Rights:

You have certain rights regarding your health information, which you can exercise by making a written request. Forms are available in our office or can be sent to you upon request.

• Access: You have the right to inspect or receive copies of your health information, usually within 30 days of your request. We may charge a reasonable cost-based fee.
• Amend: You can ask us to correct your medical record if you believe it is incorrect or incomplete. We may deny your request, but we will provide a written explanation within 60 days.
• Confidential Communications: You can request that we contact you in a specific way (e.g., home or office phone) or send mail to a different address. We will accommodate all reasonable requests.
• Restrictions: 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, but we will comply if it does not affect your care.
• Accounting of Disclosures: You can request a list of disclosures we made of your health information, excluding disclosures for treatment, payment, and healthcare operations, among others.
• Paper Copy of This Notice: You can ask for a paper copy of this notice at any time.

Changes to This Notice:

We reserve the right to change our Privacy Policy and to make the new provisions effective for all PHI we maintain. A current copy of our Privacy Policy will be posted in our office and on our website.

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 verify their authority before taking any action.

File a Complaint:

If you believe your privacy rights have been violated, you can file a complaint with our Compliance Officer at [Compliance Officer Contact Information] or with the Department of Health and Human Services Office for Civil Rights.

There will be no retaliation for filing a complaint.

For more information, visit: [HHS HIPAA Notice Page URL]