Notice of Privacy Practices Outline

We are required by law to inform you of the use and disclosure of your health information and how you can get access to your health information.  We reserve the right to make changes in our privacy practices with notification of these changes.

You will be asked to sign and acknowledge your understanding of our Privacy Practices (required by law).


Your health information will be used for:

Treatment: For coordination between health facilities to manage your health care.
Payment: To obtain payment information for services provided for health care facilities and/or insurance providers.
Healthcare Operations: To support the business practices of our practice. Inclusive of treatment, employment reviews, licensing, credentialing services, training and condition of business activities, and for contact with you about your treatment.
Business Associates: With a signed release by you information shared with a third party for treatment, marketing (services provided) and/or business operations.
Family & Friends: Disclosure of health information to a close friend, family, or relative, designated
in writing by you for your treatment and/or payment of services.
Emergencies: In an emergency treatment situation your authorization will be obtained as soon as
possible unless you are incapacitated then our professional judgment will determine the necessity of the disclosure of information to a relevant person for treatment.
Abuse & Neglect: If we believe you are a possible victim of abuse, neglect, domestic violence, or other crimes.
Military Activity & Natural Security: Disclosure of health information to Armed Forces personnel
and correctional institutions under certain circumstances

Your Rights:

Inspection & copy of health information:  Upon your request in writing, copies of your health
information with limited explanations will be provided.  There will be a reasonably
based fee for this service.
Restriction of your health information:  You may request additional restrictions of your health
information (except in emergencies).
Alternative Communication:  Upon request in writing, the place and type of communication
of your health information will be provided.
Amendment for health information:  Upon your request in writing with explanation as to why
health information changed.
Accounting of Disclosures of health information:  A request for disclosure of information other
than treatment or payment.  If requested more than once in a twelve month period a fee may be charged.
Complaint of Privacy Practices:  You may file a verbal or written complaint using the privacy
officer or Department of Health & Human Services (address provided upon request) if
you feel we have violated you privacy rights without retaliation from us.
Copy of Privacy Practices:  Available upon request.