We are required by applicable federal and state law to maintain the privacy of your health information.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided
such changes are permitted by applicable law. We reserve the right to make the changes in our privacy
practices and the new terms of our Notice effective for all health information that we maintain,
including health information we created or received before we made the changes. Before we make a
significant change in our privacy practices, we will change this Notice and make the Notice available
upon request.
We may use and disclose health information about you for treatment, payment, and healthcare operations.
For example:
Treatment: We may use or disclose your health information to a physician or other
healthcare provider providing treatment to you. An example of this would be coordinating treatment with
a specialist.
Payment: We may use and disclose your health information to obtain payment for
services we provide to you. An example of this would be sending a claim to your insurance company for
payment.
Healthcare Operations: We may use and disclose your health information in connection
with our healthcare operations. Examples of this would include quality assessment and improvement
activities, reviewing the competence or qualifications of healthcare professionals, evaluation
practitioner and provider performance, conducting training programs, accreditation, certification,
licensing or credentialing activities.
Your Authorization: In addition to our 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 a written authorization, we cannot use or
disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must 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 other person to the extent necessary to help your healthcare or with payment to
your healthcare, 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, of your location, your general condition or
death. If you are present, then prior to use or disclosure of your health information, we will provide
you with an opportunity to object to such uses or disclosures. In the event of your 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 healthcare. We will also use our professional judgment, and our 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: 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, counter intelligence, and other national security
activities. We 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: We may use or disclose your health information to provide you
with appointment reminders (such as voicemail messages, postcards, or letters).
Access: You have the right to look at or get copies of your health information with
limited exceptions. You may request that we provide copies in a format other than photocopies. We will
use the format you request unless we cannot practicably 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 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 beginning of this Notice. If you request copies we may charge you $1.00 for each page,
$15.00 per hour for staff time to locate and copy your health information, and postage if you want the
copies mailed to you. If you request an alternative format we may charge a cost-based fee for providing
your health information in that format. If you prefer we will prepare a summary or an explanation of
your health information for a fee).
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, 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 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 of 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 (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 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 web site or by electronic mail
(e-mail), you are entitled to receive this Notice in written form.
If you want more information about our privacy practices of 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 of disclosure of your health information or to have us communicate with you by alternative means
or at alternative locations, you may complain to us using the contact information listed at the
beginning of this Notice. You also may submit a written complaint to the U.S. Department of Health and
Human Services. We will provide you with the address to file your complaint with the U.S. Department of
Health and Human Services upon request.
We support your rights 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 and Human Services.
