NOTICE OF PRIVACY PRACTICES
We are required by applicable
federal and state law to maintain the privacy of your health information. We are also required to give you this Notice
about our privacy practices, our legal duties, and your rights concerning your
health information. We must follow the
privacy practices that are described in this Notice while it is in effect. This Notice takes effect (MM/DD/YR), and will
remain in effect until we replace it.
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 new Notice available upon request.
You may request a copy of
our Notice at any time. For more
information about our privacy practices, or for additional copies of this
Notice, please contact us using the information listed at the end of this
USES AND DISCLOSURES OF HEALTH
We 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
We may use and disclose your health information to obtain payment for
services we provide to you.
Healthcare Operations: We may use and disclose your health
information in connection with our healthcare operations. Healthcare operations include quality
assessment and improvement activities, reviewing the competence or
qualifications of healthcare professionals, evaluating 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 with your healthcare or with payment for 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
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, counterintelligence, 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.
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 end 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 end of this Notice. If you request copies, we will charge you
$0.___ for each page, $___ 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 will
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. Contact us using the information listed at
the end of this Notice for a full explanation of our fee structure.)
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 or
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.
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.
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.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or 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 or 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 end 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
We support your right 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.