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.
How we may use and disclose your health information.
We collect health information from you, and we store it on computers. The collected information may be used by us or our business associates for the following purposes:
To obtain payment for treatment.
For regular health care operations.
When required by federal, state, or local law, judicial or administrative proceedings, or
For public health activities.
For health oversight activities.
For research purposes.
To avoid a serious threat to health or safety.
For specific government functions.
For workers’ compensation pu
Disclosures that require your authorization.
No disclosures made for purposes other than those listed above will be made without your prior authorization, except as required or allowed by law. If you authorize us to use or disclose your information, you can revoke your authorization by notifying us in writing as described below.
You can object to these disclosures.
We may provide your information to a family member, friend, or other person that you indicate is involved in your care, treatment, or the payment for your healthcare. You may object to or restrict any of these disclosures by notifying us in writing as described below.
Your health information rights.
The Right to Request Limits on How We Use and Disclose Your Health Information. You have the right to ask that we limit how we use it and give out your information. We will carefully consider your request, but we are not required to accept it. If we accept your request, we will put it in writing and abide by it except in emergency situations. To request limits, contact us in writing as described below.
The Right to Choose How We Send Your Information to You. You have the right to ask that we send information to you to an alternate address. For example, you may ask us to send information to your work address rather than your home address. You can also ask that it be sent by alternate means. For example, you can ask that we send information by email instead of regular mail. We will agree to your request if we can easily provide it in the format you request.
The Right to See and Get Copies of Your Health Information. Most of the time, you have the right to look at or get copies / summary of your health information that we have.
You or your legally authorized representative may request to inspect or obtain a copy of your health information. If we keep any portion of your health information in an Electronic Health Record, it will be given to you (or your designee) electronically upon your request. We will provide a copy / summary within the periods established by law, and we may charge a reasonable cost-based fee. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons why and explain how you can have the denial reviewed.
The Right to Get a List of Who We Have Given Your Information To. You have the right to get a list of certain instances in which we have given out your health information after April 14, 2003. To get this list, you must verify your identification and submit it to the facility where you received your care.
The Right to Correct or Update Your Health Information. If you believe that there is a mistake in your information or that a piece of essential information is missing, you have the right to request that we correct the existing information or add the missing information. Your request and your reason for the request must be submitted in writing as described below. Each request will be carefully considered. If we approve your request, we will make the change to your information, tell you that we have done it, and tell others that need to know about the change. We may say no to your request, but we will tell you why in writing within 60 days (about 2 months).
The Right to Get This Notice. You have the right to request a copy of this notice. You also have a right to get a copy of this notice by e-mail.
The Right to Privacy Notification. You have the right to be notified after a breach of your protected health information.
Changes to our notice of privacy practices.
If our privacy practices should change at any time in the future, we will promptly change and post the new notice. We reserve the right to apply any changes to our privacy practices or this Notice to all the personal health information that we maintain, including information collected before the date of the change.
Complaints and contact information.
If you have any questions about this notice, any requests, or any complaints about our privacy practices, please contact our Privacy Officer at [email protected].
If you think that we may have violated your privacy rights, or you disagree with a decision we made about your health information, you may 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; or electronically at www.hhs.gov/ocr/privacy/hipaa/complaints.
We will not retaliate against you for filing a complaint.
Persons under the age of 18.
We do not knowingly collect information from children under eighteen (18). If you are the parent or legal guardian of a child under 18 who has provided us with information, please contact us to ask us to stop using or to delete that information.
Exercising Your rights.
You have the right to:
Request restrictions on certain uses and disclosures of your health information. We are not required to agree to the restriction you requested. Except as provided in the next paragraph, we will honor the restriction until you revoke it, or we notify you. To request restrictions, you must make your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want to the limits to apply – for example, disclosures to your spouse.
Request us to communicate with you in a certain way or at a certain location. For example, you may ask to be contacted only while at work or by email.
Be notified if we (or a Business Associate) discover a breach of unsecured protected health information.
Inspect and receive a copy of certain protected health information that may be used to make decisions about you. If the information you request is maintained electronically, and you request an electronic copy, we will provide a copy in the electronic form and format you request, if the information can be readily produced in that form and format; if the information cannot be readily produced in that form and format, we will work with you to come to an agreement on form and format. If we cannot agree on an electronic form and format, we will provide you with a paper copy.
Change or add information to your designated records; however, we may not change the “original” documents.
Request a list or an accounting of disclosures of your protected health information. However, we do not have to account for disclosures related to treatment, payment, health care operations, information provided to you, specialized government functions, and disclosures you authorize.
As required or permitted by law, you may be entitled to additional rights, including: (i) the right to control the dissemination of your personal information; (ii) the right to receive computerized personal information collected from you in a structured, commonly used and technological format and to have this information transferred directly to another organization; (iii) the right to be informed of and submit observations regarding automated decision-making; and (iv) the right to request information about data processing.
Lodge a complaint with us and/or with a competent data protection authority, particularly in the country/region where you normally reside, where we are based or where an alleged infringement of data protection law has taken place. If you file a complaint, we will not take any action against you or change your treatment in any way. If a resident of the United States, you may submit a formal complaint to:
Dept. of Health and Human Services Office of Civil Rights 200 Independence Avenue, S.W. Room 509F HHH Building Washington, DC 20201
To exercise any of these rights, please contact us as set forth in the section below “How to contact us?”
How to contact us?