Client Privacy Policy
Your Information. Your Rights. Our Responsibilities.
This notice describes how the medical information about you may be used
and disclosed. This notice will also tell how you can get access to this
information.
Please review it carefully.
Your Rights
You have certain rights when it comes to your health information. This
section explains your rights and our responsibilities to help you.
● How to obtain 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 how to do
this.
○ We will provide a copy or a summary of your health information, within 30
days of your request. There may be a fee associated with this request.
● 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 how to do this.
○ We may say “no” to your request, but we will tell you why in writing within
60 days of your request.
● Request Confidential Communications
○ You can ask us to contact you in a specific way (for example, home or
office 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”
if it would affect your care.
○ 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” to this request, unless a law requires us to share
that information.
● Get a list of those with whom we’ve shared your information
○ You can ask for a list of the times we have 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 list 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. We 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.
○ We 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 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
Or by calling 1-877-696-6775,
Or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you are able to tell us what your choices are
about what we share. If you have a clear preference for how we share your
information in the situations described below, please let us know. Tell us
what you want us to do, and we will follow your instructions.
● In these 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
○ Share information in a disaster relief situation
○ Include your information in a hospital directory
○ Contact you for fundraising efforts
● In these cases we never share your information unless you give
us written permission:
○ Marketing purposes
○ Sale of your information
○ Most sharing of psychotherapy notes
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.
● Treat you
○ We can use your health information and share it with other professionals
who are treating you.
● Run our organization
○ We can use and share your health information to run our practice, improve
your care, and contact you when necessary.
● Bill for your services
○ We can use and share your health information to bill and get payment
from health plans or other entities.
How else can we use or share your health information? We are 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 any 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
○ We can share health information about you for certain situations such as:
■ Preventing disease
■ 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
● Do research
○ We can use or share your information for health research.
● 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.
● Work with a medical examiner or funeral director
○ We can use or 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 your health information:
■ 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
○ We can share health information about you in response to a court or
administrative order, or in response to a subpoena.
Our Responsibilities
● We are required by law to maintain the privacy and security of your
protected health information.
● We will let you know promptly 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
here 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/noticeapp.html
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, in our office, and on our
website.
