Notice of Privacy Practices
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
Our commitment to your privacy
As part of providing professional care to you, we will do all we can to maintain the privacy of what is called your
“protected health information” (PHI). We are also required by law to keep your PHI private. These laws are
complicated, and we must give you this important information. This page is a shorter description of what we do to
maintain your privacy. If you would like to read the more detailed version, please ask any staff member for a copy. If
you have any questions about our practices, please contact our compliance officer, whose information is listed at the
bottom of this page.
How we use and disclose your protected health information (PHI) with your consent
We will use the information we collect about you mainly to provide you with treatment; to arrange payment for our
services; and for some other business activities called, in the law, “health care operations.” We will ask you to sign a
separate consent form to show that you understand these ways we handle your information. If you do not agree and
won’t sign this consent form, we will not treat you. If we want to use or send, share, or release your PHI for other
purposes, we will discuss this with you so you fully understand it, and ask you to sign a release-of-information form to
Disclosing your health information without your consent
There are some times when the laws require us to share your information without getting your consent. They are
described in the longer version of our Notice of Privacy Practices, but here are the most common situations:
- When there is a serious threat to your or another person’s health or safety or to the public. We will only share
information with people who are able to help prevent or reduce the danger.
- When we are required to do so by lawsuits and other legal or court proceedings.
- When a law enforcement official requires us to do so.
- For workers’ compensation and some similar programs if you seek these benefits.
Your rights about your health information
- You can ask us to communicate with you in a particular way or at a certain place that is more private for you.
For example, you can ask us to call you at home, rather than at work, to schedule or cancel an appointment.
We will try our best to do as you ask.
- You can ask us to limit what we tell people involved in your care or the payment for your care, such as family
members and friends.
- You have the right to look at the health information we have about you, such as your medical chart, case file,
and billing records. You can get a copy of these records, and we can charge you for it. Please talk to our
compliance officer to arrange how to see your records.
- If you believe that the information in our records is incorrect or missing something important, you can ask us to
make additions to your records to correct the situation. You have to make this request in writing and send it to
our compliance officer.
- You have the right to file a complaint if you believe your privacy rights have been violated. You can file a
complaint with our compliance officer and with the Secretary of the U.S. Department of Health and Human
Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you
in any way.
- You have the right to a copy of this notice.
Also, you may have other rights that are granted to you by the laws of our state, and these may be the same as or
different from the rights described above. Our compliance officer will be happy to discuss these situations or answer
any questions now or as they arise. Here are the officer’s name and contact information: Richard Weyler MD ,
Kristin Vosburg LCSW firstname.lastname@example.org