This notice describes how medical information about you may be used and disclosed and how you get access to this information. We are required by law to maintain the privacy of your protected health information, to notify you of our legal duties and privacy practices with respect to your health information, and to notify affected individuals following a breach of unsecured protected health information. This Notice summarizes our duties and your rights concerning your information. Our duties and your rights are set forth more fully in 45 CFR Part 164.
Your Rights: When it comes to your health information, you have certain rights. Please review carefully.
- You can ask to see or get an electronic/paper copy of your medical record and other health information we have about you.
- 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. We may say no to your request, but we will tell you why in writing.
- You can ask us to contact you in a specific way (ex: home or office phone) or send mail to a different address. We will say yes to all reasonable requests.
- You can ask us to limit sharing of certain health information for treatment, payment, or our operations. We are not required to agree to your request and may say no if it would affect your care.
- If you pay for a service or healthcare 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 insurer. We will say yes unless a law requires us to share that information.
- You can ask for a paper copy of this notice at any time.
- 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 authority and can act for you before we take any action.
Your Choices: For certain health information, you can tell us your choice on what we share. If you have a clear preference for how
we share your information, talk to us.
- You have both the right and choice to share information with your family, friends, or others involved in your care.
- We never share your information for marketing purposes, sale of your information, and most psychotherapy notes.
Other Uses and Disclosures: We share your information to treat you, run our organization, and/or bill for services.
- We can use your health information and share it with other professionals who are treating you.
- 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 information to bill and get payment from health plans or other entities.
- We are allowed/required to share your information in ways that contribute to public good such as preventing disease, product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, and preventing/reducing a serious threat to anyone’s health or safety.
- We will share your information if state or federal laws require it, including the Department of Health and Human Services.
- We can share health information with organ/tissue organizations per request, coroner, medical examiner, or funeral director.
- We can share information for workers’ compensation claims, for law enforcement purposes, health oversight agencies authorized by law, and government functions such as military, national security, presidential protective services, and in response to a court order or subpoena.
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 share your information other than as described there unless we have written consent.
We participate in one or more Health Information Exchanges. Your healthcare providers can use this electronic network to securely provide access to your health records for a better picture of your health needs. We, and other healthcare providers, may allow access to your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by notifying your physician’s office.
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 website.
If you have any questions about this notice or would like to file a complaint, please contact our privacy officer listed below:
Kathleen Kostelnick · (330) 899-9350 ext 2024 · 3515 Massillon Rd. Suite 300, Uniontown, Ohio 44685 · firstname.lastname@example.org