NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your Information. Your Rights. Our Responsibilities.

Summary of Our Privacy Practices

Your Rights – You have the right to:

  • Get a copy of your paper or electronic medical record
  • Correct your paper or electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this Notice of Privacy Practices
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated

Your Choices – You have some choices in the way that we use and share information as we:

  • Tell family and friends about your condition
  • Provide disaster relief
  • Provide mental health care
  • Market our services and sell your information
  • Raise funds

Our Uses and Disclosures – We may use and share your information as we:

  • Treat you
  • Run the Practice
  • Bill for your services
  • Help with public health and safety issues
  • Do research
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Address workers’ compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions

Substance Use Disorder Information: To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

Details of Our Privacy Practices

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us for the Practice’s form, which you will complete, sign, and submit to the Practice to make your request.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us for the Practice’s form, which you will complete, sign, and submit to the Practice to make your request.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home, office, or cell phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this Notice of Privacy Practices

  • You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

  • If someone has authority to act as your personal representative, such as if someone has been designated as your health care representative under state law or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action with respect to your health information.

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contacting us using the following information:_________________________
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html.
  • We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we use and share. If you have a clear preference for how we use and share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In the following cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care or payment for your care
Share information in a disaster relief situation
In the case of fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again about fundraising

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe in our professional judgment it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In the following cases we never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

In the case of fundraising:

  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

If we have your substance use disorder patient records, subject to 42 CFR Part 2, we will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways and can do so without your permission, unless otherwise noted:

  • Treat you. We can use your health information, and with your consent, we can share your health information with other professionals who are treating you. Example: A nurse practitioner treating you for Alzheimer’s asks another doctor about your overall health condition.
  • Run our Practice. We can use your health information, and with your consent, we can share your health information, to run our Practice, improve your care, and contact you when necessary. Example: We may use and disclose health information about you for purposes of internal administration and planning, quality review and improvement, legal services, etc.
  • Bill for your services. We can use your health information, and with your consent, we can share your health information, to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

We may share information electronically through a Health Information Exchange (HIE).

How else can we use or share your health information?

We are allowed or required to share your information in other ways without your consent or authorization. We have to meet many conditions in the law before we can share your information for these purposes.  

Substance Use Disorder Records. Federal law imposes strict limitations on the use and disclosure of substance use disorder treatment records subject to 42 CFR Part 2. In all cases, including those listed below, if we have such records about you, those records (and testimony relaying the content of those records) cannot be used or shared by us in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your specific written consent or (2) a court order (after notice and an opportunity to be heard is provided) accompanied by a subpoena or other legal requirement compelling disclosure.

Help with public health and safety issues.

We can share health information about you for certain situations such as:

  • Preventing or controlling disease, injury or disability
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, rape, sexual assault, domestic violence
  • Preventing or reducing a serious and imminent threat to anyone’s health or safety if the disclosure is to a person who is reasonably able to lessen or prevent the threat, including the target of the threat
  • Alerting your fiancée, if you are engaged, or your spouse, if you are married, of a sexually transmitted infection
  • Filing a death certificate.

Communicate with you about products and services.

We may use your health information to communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings. We also may use your health information to identify health-related services and products provided by us that may be beneficial to your health and then contact you about the services and products. We will not use or share your health information for purposes of marketing (as defined by federal privacy laws) without first obtaining your permission.

Do research.

We can use or share your information for research if an Institutional Review Board/Privacy Board approves a waiver of authorization for such use or disclosure, and under other limited circumstances.

Comply with the law.

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Comply with health oversight agencies and public health authorities.

We may disclose your health information, including treatment records, in response to a written request by any federal or state governmental agency to perform legally-authorized functions, such as management audits, financial audits, program monitoring and evaluation, and facility or individual licensure or certification.

Respond to organ and tissue donation requests.

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director.

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests.

We can use or share health information about you:

  • For workers’ compensation claims as required under applicable laws
  • In the course of a judicial or administrative proceeding in response to a legal order or other lawful process
  • For law enforcement purposes or with a law enforcement official as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena accompanied by a court order
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services

Highly Confidential Information

Federal and state law require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including: (1) your HIV/AIDS status; (2) genetic testing information; (3) substance use disorder information protected under 42 CFR Part 2; (4) confidential communications with a psychotherapist, psychologist, social worker, sexual assault counselor, domestic violence counselor, or other allied mental health professional, or human services professional; (5) sexually transmitted infection (STI) information; (6) mammography records; (7) mental health community program records; (8) research involving controlled substances; (9) abortion consent form(s); and (10) family planning services (funded by the Department of Public Health). In order for us to share your Highly Confidential Information, we must obtain your separate, specific written consent and/or authorization unless we are otherwise permitted by law to make such disclosure. Most uses and disclosures involving Psychotherapy Notes (as defined in the Federal privacy regulations) require your authorization. If you are an emancipated minor, certain information relating to your treatment or diagnosis may be considered “Highly Confidential Information” and as a result will not be disclosed to your parent or guardian without your consent. Your consent is not required, however, if a physician reasonably believes your condition to be so serious that your life or limb is endangered. Under such circumstances, we may notify your parents or legal guardian of the condition, and will inform you of any such notification. Please note that if you are a parent or legal guardian of an emancipated minor, certain portions of the emancipated minor’s medical record (or, in certain instances, the entire medical record) may not be accessible to you.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this Notice and give you a copy of it.
  • We will not use or share your information other than as described in this Notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Other

  • Re-Disclosure. When we share your health information in accordance with this Notice, including substance use disorder information, we cannot guarantee that the recipient will not re-disclose your health information to a third party or that your health information will continue to be protected by federal privacy laws.
  • Changes to the Terms of this Notice. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request, at the Practice, and on our web site.
  • Compliance Officer Contact Information. You may contact our Compliance Officer at: [insert name and contact info – phone number, email address, mailing address]
  • Questions, Additional Information, Exercising Your Rights. If you have questions regarding information contained in this Notice, if you would like to obtain additional information about our privacy practices, or if you wish to exercise your rights as listed in this Notice, you may contact our Compliance Officer.
  • Effective Date. This Notice is effective as of _________________, 2026.