NOTICE OF PRIVACY PRACTICES

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.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record.

We may charge a reasonable, cost-based fee.

Ask us to correct your medical record.

Request confidential communications.

Ask us to limit what we use or share.

Get a list of those with whom we have shared information.

and certain other disclosures [such as any you asked us to make). We 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.

Choose someone to act for you.

File a complaint if you feel your rights are violated.

Your Choices

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:

[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:

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you.

Run our organization.

[Example: We use health information about you to manage your treatment and services.]

Bill for your services

How else can we use or share your health information?

Help with public health and safety issues.

We can share health information about you for certain situations such as:

Do research.

Comply with the law.

Respond to organ and tissue donation requests.

Work with a medical examiner or funeral director

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

Respond to lawsuits and legal actions.

Our Responsibilities

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 upon request, in our office, and on our web site.

This Notice of Privacy Practices applies to the following organizations.