top of page

Privacy Policy

Happy Woman


Effective Date: January 9, 2017


We are required by law to maintain the privacy of protected health information, to provide individuals
with notice of our legal duties and privacy practices with respect to protected health information, and to
notify affected individuals following a breach of unsecured Protected health information. This notice
describes how we may use and disclose your medical information. It also describes your rights and our
legal obligations with respect to your medical information. If you have any questions about this Notice,
please contact us.

Your Rights

You have the right to:
• Get a copy of your paper or electronic medical record. Ask us how to do this. We will provide a copy of
or a summary of your health information, usually within 30 days of your request. We may charge a
reasonable, cost-based fee.

• Ask us to correct your paper or electronic medical record. We may not agree to your request, but we’ll
tell you why in writing within 60 days.

• Request confidential communication. We will agree to all reasonable requests.

• Ask us to limit the information 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 not agree if it would affect your care. If you pay for a service of 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 agree, unless a law requires us to share that information.

• Get a list of those with whom and why we've shared your information for six years prior to the
date you ask. 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.

• Get a copy of this Notice of Privacy Practices. You can ask for a paper copy of this notice at any time.
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 take reasonable actions to ensure any such person has this authority and can act
for you before we take any action.

• File a Complaint. You can complain, if you feel we have violated your privacy rights by contacting us at
the phone number listed above. 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, 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

 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

Our Uses and Disclosures

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
• 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 information to bill and get payment from health plans
or other entities.

We are allowed or required to share your information in other ways as provided below – 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
• 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.
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 visit:


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 web site

bottom of page