Your Information. Your Rights. Our Responsibilities. This document details how your medical information may be used and shared, and how you can access it. Please read it carefully.

Your Rights Regarding Your Health Information

You possess specific rights concerning your health information. This section clarifies these rights and outlines some of our duties to support you.

1. Obtain a Copy of Your Medical Record (Electronic or Paper): You may request access to or a copy of your medical record. We will typically provide it within 30 days, for a reasonable, cost-based fee.
2. Request Corrections: If you believe information is inaccurate or incomplete, you can ask for a correction. We may deny it but will respond within 60 days.
3. Request Confidential Communications: You may ask us to contact you in a specific way or send mail to a different address. We will comply with reasonable requests.
4. Restrict Information Sharing: You may request limits on our use or sharing of your data. We may deny the request unless you pay out-of-pocket in full for a service and ask us not to share it with your health insurer.
5. Receive a Copy of This Notice: You can request a paper copy of this notice at any time.
6. Designate Someone to Act for You: A legal guardian or someone with medical power of attorney may exercise your rights on your behalf.
7. File a Complaint: Contact us or the U.S. Department of Health and Human Services if you believe your rights have been violated. We won’t retaliate.

Your Choices Regarding Information Sharing

You can direct us on how to share your information in specific situations. If you're unable to express a preference, we may act in your best interest.

1. Share with family, friends, or others involved in your care.
2. Share during disaster relief efforts.
3. Include you in a hospital directory.

We will never share your information unless you give us written permission in these cases:

1. For marketing purposes
2. Sale of your information
3. Most sharing of psychotherapy notes

Fundraising: We may contact you, but you can opt out at any time.

How We Use and Disclose Your Health Information

1. To Provide Treatment: We can use and share your information with other healthcare providers. Example: A dentist consulting your oral surgeon.
2. For Operations: For managing our practice and improving care. Example: Coordinating your treatment plan.
3. For Billing: For payment processing. Example: Submitting claims to your insurance.

Other Permitted Uses

We are allowed or required to share your information in ways that contribute to public health and research:

1. Prevent disease spread
2. Product recalls
3. Report adverse medication reactions
4. Report abuse, neglect, or domestic violence
5. Prevent serious threats to health or safety
6. Health-related research
7. As required by law

Additional Sharing Scenarios

1. Organ and Tissue Donation: We may share with donation organizations.
2. Medical Examiners & Funeral Directors: We may share as needed.
3. Workers’ Compensation, Law Enforcement, and Government: For authorized activities like military or national security services.
4. Legal Proceedings: In response to court orders or subpoenas.

Our Responsibilities

1. Maintain privacy and security of your health data.
2. Notify you promptly in case of a data breach.
3. Follow the terms outlined in this notice.
4. Only share your data with your written permission, which you can revoke at any time.

For more details, see our full Privacy Policy.

Changes to the Terms of This Notice

We may update this notice, and the revised version will apply to all your information. The updated notice will be available in our office and on our website.

This notice applies to all entities listed on our site. Please refer to the specific page for contact details.

HIPAA Office Contact Information

1. HIPAA Entity:
2. Civil Rights Coordinator:
3. Civil Rights Coordinator Title:
4. Address:
5. Phone:
6. TTY (if applicable):
7. Email:
8. Fax: