Your Information. Your Rights. Our Responsibilities.
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.
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask me to limit the information I share
- Get a list of those with whom I’ve shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
You have some choices in the way that I use and share information as I:
- Tell family and friends about your condition
- Provide disaster relief
- Include you in a hospital directory
- Provide mental health care
- Market our services and sell your information
Our Uses and Disclosures
I may use and share your information as I:
- Help with public health and safety issues
- Respond to organ and tissue donation requests
- Work with a medical examiner or funeral director
- Address workers’ compensation, law enforcement, and other government
- Respond to lawsuits and legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities.
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 I have about you. Ask me how to do this.
- I will provide a copy or a summary of your health information, usually within 30 days of your request. I may charge a reasonable, cost-based fee.
Ask me to correct your medical record
- You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to.
- I may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
- You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address
- I will say “yes” to all reasonable requests.
Ask me to limit what we use or share
- You can ask me not to use or share certain health information for treatment, payment, or our operations. I am not required to agree to your request, and may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask me not to share that information for the purpose of payment or our operations with your health insurer. I will say “yes” unless a law requires me to share that information.
Get a list of those with whom I’ve shared information
- You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). I’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 privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. I will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- I will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel I have violated your rights by contacting me using the information on page 1.
- 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 www.hhs.gov/ocr/privacy/hipaa/complaints/
- I will not retaliate against you for filing a complaint.
For certain health information, you can tell me your choices about what I share. If you have a clear preference for how I share your information in the situations described below, talk to me. Tell me what you want me to do, and we will.
In these cases, you have both the right and choice to tell me to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
- If you are not able to tell me your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases I will never share your information unless you give me written permission:
- Sale of your information
- Most sharing of psychotherapy notes
- I may contact you for fundraising efforts, but you can tell us not to contact you again.
How do I typically use or share your health information?
I typically use or share your health information in the following ways.
I can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
I can use and share your health information to run our practice, improve your care, and contact you when
Example: I use health information about you to manage your treatment and services.
I can use and share your health information to bill and get payment from health plans or other entities.
Example: I give information about you to your health insurance plan so it will pay for your services.
How else can I use or share your health information?
I am allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
I can share health information about you for certain situations such as:
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
I can use or share your information for health research.
I 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 I’m complying with federal privacy law.
Respond to organ and tissue donation requests
I can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
I 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
I can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
I can share health information about you in response to a court or administrative order, or in response to a
• I am required by law to maintain the privacy and security of your protected health information.
• I will let you know promptly if a breach occurs that may have compromised the privacy or security of your
• I must follow the duties and privacy practices described in this notice and give you a copy of it.
• I will not use or share your information other than as described here unless you tell me I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
I can change the terms of this notice, and the changes will apply to all information I have about you. The new notice will be available upon request, in my office, and on our web site.
Other Instructions for Notice
• Notice Effective Date: September 22, 2013
• Privacy Officer: Ronda Gallawa, M.A., Licensed Professional Counselor Intern