​NOTICE OF PRIVACY PRACTICES
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT.

LEGAL DUTY

I am required by applicable federal and state law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices, my legal duties, and your rights concerning your health information. I must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until I replace it.

I reserve the right to change my privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. I reserve the right to make changes in my privacy practices and the new terms of my Notice effective for all health information that I maintain, including health information I created or received before I made the changes. Before I make a significant change in my privacy practices, I will change this Notice and make the new Notice available upon request.

You may request a copy of my Notice at any time. For more information about my privacy practices, or for additional copies of this Notice, please contact me using the information listed at the top and end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

I use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment:  I may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment:  I may use and disclose your health information to obtain payment for services I provide for you.

Healthcare Operations:  I may use and disclose your health information in connection with my healthcare operations.  Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization:  In addition to my use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose.  If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, I cannot use or disclose your health information for any reason except those described in this Notice. 

To Your Family and Friends:  I must disclose your health information to you, as described in the Patient Rights section of this Notice. I may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree with written consent that I may do so.

Persons Involved in Care:  I may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, I will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, I will disclose health information based on a determination using my professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. I will also use my professional judgment and my experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of health information.

Marketing Health-Related Services:  I will not use your health information for marketing communications without your written authorization.

Required by Law:  I may use or disclose your health information when I am required to do so by law.

Abuse or Neglect:  I may disclose your health information to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. I may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. 

National Security:  I may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. I may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. I may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders:  I may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENTS RIGHTS

Access:  You have the right to look at or get copies of your health information, with limited exceptions. You may request that I provide copies in a format other than photocopies. I will use the format you request unless I cannot practically do so.  You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the beginning or end of this Notice. I will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending me a letter to the address listed in this Notice. If you request copies, I will charge you a fee to locate and copy your health information, and postage if you want the copies mailed to you.  If you request an alternative format, I will charge a cost-based fee for providing your health information in that format. If you prefer, I will request an alternative format, I will charge a cost-based fee for providing your health information in that format. If you prefer, I will prepare a summary or an explanation of your health information for a fee. Contact me using the information listed in this Notice for a full explanation of my fee structure.

Disclosure Accounting:  You have the right to receive a list of instances in which I or my business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003.  If you request this accounting more than once in a 12-month period, I may charge you a reasonable, cost-based fee for responding to these additional requests. 

Restriction:  You have the right to request that I place additional restrictions on my use or disclosure of your health information. I am not required to agree to these additional restrictions, but if I do, I will abide by my agreement (except in an emergency). 

Alternative Communication:  You have the right to request that I communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing.  Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment:  You have the right to request that I amend your health information. Your request must be in writing, and it must explain why the information should be amended. I may deny your request under certain circumstances. 

Electronic Notice:  If you receive this Notice on my Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form. 

QUESTIONS AND COMPLAINTS

If you want more information about my privacy practices or have questions or concerns, please contact me.

If you are concerned that I may have violated your privacy rights, or you disagree with a decision I made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have me communicate with you by alternative locations, you may complain to me using the contact information listed at the beginning and end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. I will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

 I support your right to the privacy of your health information.  I will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.