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.
Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of your health information. We are also
required to give you this Notice about our privacy practices, our legal duties and your rights concerning your health
information. We must follow the privacy practices that are described in the Notice while it is in effect. This Notice takes
effect April 14, 2003, and will remain in effect until we replace it.
Uses and Disclosures of Health Information
We use and disclose health information about you for treatment, payment and health care operations.
Treatment: We may use or disclose your health information to a physician or other health care provider providing
treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Health Care Operations: We may use and disclose your health information in connection with our health care operations.
Health care operations include quality assessment and improvement activities, reviewing the competence or
qualifications of health care professionals, evaluating practitioner and provider performance, conducting training
programs, accreditation, certification, licensing or credentialing.
Your Authorization: In addition to our use of your health information for treatment, payment or health care 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 authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures
permitted by your authorization when it was in effect. Unless you give us a written authorization, we cannot use or
disclose your health information for any reason except those described in this Notice or allowed under the law.
To Your Family and Friends: We may disclose your health information to you, as described in the Patient Rights section of
this Notice. We may disclose your health information to a family member, friend or another person to the extent necessary
to help with your health care or with payment for your health care, but only if you agree that we may do so.
Persons Involved in Care: We 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, your
location, your general condition or death. If you are present, then prior to the use or disclosure of your health, incapacity
or emergency circumstances, we will disclose health information based on a determination using our professional
judgment, disclosing only health information that is directly relevant to the person’s involvement in your health care. We
will allow a person to pick up filled prescriptions, medical supplies, X-rays or other similar forms of health information only
upon your written authorization. In case of your incapacity, we will use our professional judgment and our experience
with common practice to make reasonable inferences of your best interest in providing prescriptions, medical supplies,
X-rays and/or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without
your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe
that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes.
We 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: We may disclose to military authorities the health information of armed forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence and other national security activities. We may disclose to a correctional institution or law enforcement official having lawful custody of protected health information of inmates or patients under certain circumstances.
Appointment Reminders: We may use or disclose a portion of your health information to provide you with the results
of tests, procedures and/or appointment reminders (such as voice mail messages, postcards or letters).
Patient Rights
Access: You have the right to look at or obtain copies of your health information, with limited exceptions. 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 end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $1 for each page, $15 per hour for staff time to locate and copy your health information and postage if you want the copied mailed to you. If you prefer, we will provide a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, health care 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,
we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations, unless we cannot practically do so. (You must make your request in writing.) Your request must specify the alternative means or location and provide a satisfactory explanation of how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing,
and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our website or by electronic mail (email), you are entitled to receive this Notice in written form.
Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we 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, you may complain to us using the contact information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health & Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health & Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health & Human Services.