Your Information. Your Rights. Our Responsibilities.

This document details how your medical information may be used and disclosed. Also, how you can acquire access to this information. Please review this document carefully.

Your Rights

You have the right to:

  • Obtain a copy of your digital or physical medical record
  • Make corrections to your digital or physical medical record
  • Request confidential communication
  • Request we limit the information we disclose
  • Obtain a list with whom we’ve disclosed your information to
  • Access a copy of this privacy disclosure document
  • Delegate someone to act on your behalf
  • File a complaint if you believe your privacy rights have been violated in accordance with what is detailed in this document

Your Choices

You have several choices regarding the way we use and disseminate information as we:

  • Disclose information about your medical condition to family and/or friends
  • Provide disaster relief
  • Incorporate your information into a hospital directory
  • Provide behavioral health and substance use disorder care
  • Market our services digitally and/or physically, and vend your information
  • Secure funding

Our Uses And Disclosures

We may use and share your information as we:

  • Provide treatment to you
  • Operate our organization
  • Invoice for services rendered
  • Assist with public health and safety issues
  • Conduct research
  • Comply with industry laws and regulations
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Confront workers’ compensation, law enforcement, and other government requests
  • Reply to lawsuits and legal actions taken against our organization

Your Rights

You’re afforded certain rights when it comes to your health information. The following section details your rights and our organizations responsibilities to assist you.

Obtain An Electronic Or Physical Copy Of Your Medical Record

  • Request access to a digital or physical copy of your medical record and/or other personal health information.
  • A copy or summary of your health information will be provided to you upon request, usually within 30 business days. A reasonable fee may be charged upon request.

Request To Revise Your Medical Record

  • Personal health information you believe to be incorrect or incomplete can be corrected upon request.
  • Your request may be denied, but a detailed explanation will be given within 60 business days.

Request Access To Confidential Communications

  • A specific form of contact (e.g., mobile, work or home phone) can be requested or any changes to a mailing address
  • Any requests deemed unreasonable will be denied.

Request To Limit The Information We Use Or Disclose

  • You can request certain personal health information to not be used or disclosed regarding treatment, payment, or operations of our organization. We’re not obligated to satisfy your request, and your request may be denied if it would affect your treatment.
  • Payment, out-of-pocket and in total, of a service or any health care item during your treatment can be requested to not be disclosed for the purpose of payment or our organizations operations with your health insurer. Such requests will be granted unless a law or regulation requires us to share that information.

Obtain A List With Whom We’ve Disclosed Information To

  • You can request a breakdown, prior to six years of the request date, of the times we’ve shared your personal health information, including an explanation.
  • Excluded in the breakdown will be all the disclosures of information pertaining to treatment, payment, and health care operations, including certain other disclosure (e.g., any you requested our organization to create). This breakdown will be provided upon request free of charge once annually and a reasonable fee will be applied to additional requests within the same year.

Obtaining A Copy Of This Privacy Document

  • Upon request, a physical copy of this privacy document will be promptly provided to you even if you have agreed to receiving this document digitally.

Delegating Someone To Act For You

  • Any person you have given medical power of attorney or is your legal guardian can exercise your rights and make decisions about your health information.
  • This person will be vetted to confirm they have this authority, and we can act in your best interest before we take any action

File A Complaint If You Feel Your Rights Are Violated

  • If you feel we have violated your rights, then you can file a formal complaint by using the contact information provided on page 1.
  • It is your right to file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by mailing a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/.
  • There will be zero retaliatory measures taken against you if a complaint is filed.

Your Decisions

  • It is your right to instruct us on how we disclose certain personal health information. If you have a clear preference for how we disclose your health information in certain situations described below, contact us. Inform our organization on the procedures we should use, and we will follow your instructions.

    In these situations, you have both the right and choice to instruct our organization to:

    • Disclose information to your family, friends, or others involved in your treatment
    • Disclose information in a disaster relief situation
    • Include your information in a hospital directory

    If you’re unable to inform our organization about your preference (e.g., you’re unconscious), then our organization may disclose your information if we believe it is in your best interest. Also, your information may be disclosed if it is needed to lessen or deter a serious and imminent threat to health or safety. Our organization will never disclose your information unless expressly authorized through written or verbal permission for:

    • Marketing purposes
    • Sale of your information
    • Disclosing of psychotherapy notes

    Regarding the circumstance of fundraising:

    • We may contact you for fundraising efforts, but you can inform us to never contact you again.

Our Uses And Disclosures

  • What is our organizations typical use or disclosure of your health information?

    We typically use or disclose your health information in the following ways:

Treatment

  • We can use your health information and share it with other professionals who are treating you.
    Example: A doctor treating you for an injury asks another doctor about your overall health condition.

    We may disclose your health information to other professionals who are treating you (e.g., if you’re being treated for an injury and the primary care physician requests a second prognosis of your overall health condition).

Organization Operations

  • Our organization can use and disclose your health information to conduct our operations, improve your treatment/care, and contact you when necessary (e.g., your health information being disclosed to improve or manage your treatment.)

Invoicing For Services Rendered

  • Our organization can use and disclose your health information to invoice and receive payment from health plans or other entities (e.g., we provide your health insurance with your personal health information so it will pay for rendered services).

Other Ways Our Organization Can Use Or Disclose Your Health Information?

  • Our organization is allowed or required to disclose your personal health information in a myriad of ways, including but not limited to contributing to the public good (e.g., public health, research, and studies). We are obligated to follow many requirements by the law before we can disclose your information for these purposes. To learn more, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Assisting With Public Health And Safety Issues

  • Our organization can disclose your health information for certain circumstances such as:

    • Preventing disease
    • Assisting with product recalls
    • Reporting adverse reactions to medications
    • Reporting suspected abuse, neglect, or domestic violence
    • Preventing or reducing a serious threat to anyone’s health or safety

Conducting Research

  • Our organization can use or disclose your personal health information for health research.

Complying With The Law

  • Our organization will disclose your personal health information to comply with state or federal laws, including the Department of Health and Human Services if requested.

Responding To Organ And Tissue Donation Requests

  • Our organization can disclose your personal health information with organ procurement organizations.

Aiding A Medical Examiner Or Funeral Director

  • Our organization can disclose your personal health information with a coroner, medical examiner, or funeral director upon the death of an individual.

Confronting Workers’ Compensation, Law Enforcement, And Other Government Requests

  • Our organization can use or disclose your personal health information for:

    • Workers’ compensation claims
    • Law enforcement purposes or with a law enforcement official
    • Law authorized activities for health oversight agencies
    • Special government functions (e.g., military, national security, and presidential protective services)

Replying To Lawsuits And Legal Actions

  • Our organization can disclose your personal health information in reply to a subpoena and court or administrative order.

Our Responsibilities

    • Our organization is required by law to maintain the privacy and security of your protected personal health information.
    • Our organization will promptly inform you of any breach that occurs that may compromise the privacy or security of your personal health information.
    • Our organization must follow the regulations, duties and privacy practices detailed in this disclosure document and will provide you a digital and/or physical copy.
    • Our organization will not use or disclose your personal health information for any purpose other than what is detailed in this document unless expressly authorized in written or verbal communication. If authorized and you decide to revoke our organizations authority, then you can inform us in writing.

    To learn more, see: https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html.

Changes To The Terms Of This Document

    • Our organization can change the terms of this privacy document at any time and the revisions will apply to all your information. Upon request, the revised document will be readily available in our office(s) and accessible on our web site.

Other Instructions For Notice

    • Effective Date of this Notice: October 31, 2023.
    • Our organization will never market or sell your personal information.