This Notice outlines how your medical information may be used and shared, and how you can access it. Please read it carefully.

Your health record contains Protected Health Information (PHI), which is personal information about your past, present, or future health. Under the Health Insurance Portability and Accountability Act (HIPAA), your provider must keep your PHI private and follow the terms of this Notice. They can change this Notice, and any new version will apply to all your PHI. You can request a copy of the updated Notice by mail or at your next appointment.

HOW YOUR PROVIDER MAY USE AND DISCLOSE YOUR HEALTH INFORMATION:

1. For Treatment: Your PHI may be shared with those providing your care to coordinate treatment. Authorization is required for disclosure to other consultants.
2. For Payment: Your PHI may be used to obtain payment for services, including processing insurance claims. Only necessary PHI will be shared for collections if needed.
3. For Health Care Operations: Your PHI may be used for business activities, such as quality assessments, and shared with third parties under privacy agreements.
4. Required by Law: Your PHI will be disclosed upon your request and to government agencies as mandated.
5. Without Authorization: Limited disclosures may occur without your consent for legal requirements, court orders, or to prevent serious threats to health or safety.
6. Verbal Permission: Your provider may share information with family members involved in your treatment with your verbal consent.
7. With Authorization: Any other uses or disclosures require your written consent, which you may revoke.

YOUR RIGHTS REGARDING YOUR PHI:

– Right to Access and Copy: You can inspect and copy your PHI unless access could cause you harm. A reasonable fee may be charged for copies.

– Right to Amend: You can request corrections to inaccurate or incomplete PHI, but your provider is not obligated to make changes.

Right to an Accounting of Disclosures: You can request a list of certain disclosures of your PHI.

COMPLAINTS

If you believe your privacy rights have been violated, you may submit a complaint with the Federal Government. Filing a complaint will not affect your right to further treatment or future treatment. To file a complaint with the Federal Government, contact:

Secretary of the U.S. Department of Health and Human Services

200 Independence Avenue, SW

Washington, DC 20201

(202) 619-0257

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

***I acknowledge receipt of the Notice of Privacy Practices, which explains my rights and the limits on ways my provider may use or disclose personal health information to provide service.