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. 

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 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 we  use and share information as we:  

• 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

• Raise funds 

We may use and share your information as we: 

• Treat you 

• Run our organization 

• 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 

• 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, usually within 30  days of your request. We may charge a reasonable, cost-based fee. 

• 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’ll tell you why in writing within 60 days. 

• 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. 

• 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” unless a law requires us to share that 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. 

• 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. 

• 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. 

• You can complain if you feel we have violated your rights by contacting us 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

• 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 share. If you have a clear preference for how we 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 these cases we never share your information unless you give us written permission: 

• 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 us your preference, for example if you are unconscious,  we may go ahead and share your information if we believe 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. 

• 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. 

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. 

• We 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. 

Run our organization 

Bill for your services 

• We can use and share your health  information to run our practice, improve  your care, and contact you when necessary. 

• We can use and share your health  information to bill and get payment from  health plans or other entities.  

Example: We use health information about you to manage your treatment and  services.  

Example: We give information about you to your health insurance plan so it will pay for your services. 

Notice of Privacy Practices

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 many conditions in the law before we can share your information for these purposes. For more  information see:


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