Note: 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.

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Effective date: This notice takes effect June 1, 2023, and stays in effect until replaced by another notice.

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When you receive treatment or benefits from our practice, we receive, create and maintain information about your health, treatment, and payment for services. We will not use or disclose your information without your written authorization (permission) except as described in this notice.

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How We May Use and Disclose Your Health Information

We may use and disclose your health information without your authorization for treatment, payment, and health care operation purposes. Examples include but are not limited to:

• Using or sharing your health information with other health care providers involved in your treatment or with a pharmacy that is filling your prescription.

• Using or sharing your health information with your health plan to obtain payment for services or using your health information to determine your eligibility for insurance benefits.

 

We may share your health information with our business associates who need the information to perform services on our behalf and agree to protect the privacy and security of your health information according to agency standards.

 

We may use or share your health information without your authorization as authorized by law to family or friends involved in your care.

 

We may use and disclose your health information without your authorization to contact you for the following activities, as permitted by law and agency policy: providing appointment reminders; describing or recommending treatment alternatives; or providing information about health-related benefits and services that may be of interest to you.

 

We may also use and disclose your health information without your authorization for the following purposes:

• To alert appropriate authorities about victims of abuse, neglect, or domestic violence; if the agency reasonably believes you are a victim of abuse, neglect, or domestic violence we will make every effort to obtain your permission, however, in some cases we may be required or authorized to alert the authorities;

• For judicial and administrative proceedings such as responding to a subpoena or other lawful order;

• For law enforcement purposes such as identifying or locating a suspect or missing person;

• To avert a serious threat to health or public safety;

• For incidental disclosures such as when information is overheard in a waiting room despite reasonable steps to keep information confidential; and

• As otherwise required or permitted by local, state, or federal law.

 

Additional privacy protections under state or federal law apply to substance abuse information, mental health information, certain disease-related information, or genetic information. We will not use or share these types of information unless expressly authorized by law.

 

Your Privacy Rights

Although your health record is the property of our practice, you have the right to:

• Inspect and copy your health information, including lab reports, upon written request and subject to some exceptions. We may charge you a reasonable, cost-based fee for providing records as permitted by law.

• Receive confidential communications of your health information, such as requesting that we contact you at a certain address or phone number. You may be required to make the request in writing with a statement or explanation for the request.

• Request amendment of your health information in our records. All requests to amend health information must be made in writing and include a reason for the request.

• Request an accounting (a list) of certain disclosures of your health information that we make without your authorization. You have the right to receive one accounting free of charge in any twelve-month period.

• Request that we restrict how we use and disclose your health information for treatment, payment, and health care operations, or to your family and friends. We are not required to agree to your request, except when you request that we not disclose information to your health plan about services for which you paid with your own money in full.

• Obtain a paper copy of this notice upon request.

 

Our Duties

We are required to provide you with notice of our legal duties and our privacy practices with respect to your health information. We must maintain the privacy of information that identifies you and notify you in the event your health information is used or disclosed in a manner that compromises the privacy of your health information.

 

We are required to abide by the terms of this notice. We reserve the right to change the terms of this notice and to make the revised notice effective for all health information that we maintain. We will post revised notices on our public website and in waiting room areas. You may request a copy of the revised notice at the time of your next visit.

 

Complaints

If you feel that your rights have been violated:

• You may also file a complaint by contacting the Office for Civil Rights, Region VI, U.S. Department of Health and Human Services, by mail at 1301 Young St., Suite 1169, Dallas, Texas 75202; by telephone at (800) 368-1019, (214) 767-0432 (fax), or (800) 537-7697 (TDD). You can also visit https://www.hhs.gov/ocr/privacy/hipaa/complaints. 

 

For complaints about a violation of your right to confidentiality by an alcohol or drug abuse treatment program, contact the United States Attorney’s Office for the judicial district in which the violation occurred.

We will not retaliate against you for filing a complaint.