Notice of Privacy Practices

This notice applies to [PRACTICE LEGAL NAME / DBA] and the covered entities and locations described at the end of this notice. It explains how we may use and disclose your protected health information, your privacy rights, and our responsibilities.

Your Rights

Get an Electronic or Paper Copy of Your Health Information

• You may ask to see or receive an electronic or paper copy of your medical record and other health information maintained in a designated record set, subject to limited exceptions allowed by law.
• When available, you may view, download, or transmit information through our secure patient portal. You may also request a copy in the electronic form and format you request when it is readily producible, or in another agreed form and format.
• We will respond within the time required by applicable law. We may charge only a reasonable, cost-based fee permitted by law.

Ask Us to Correct or Amend Your Health Information

• You may ask us to amend information you believe is incorrect or incomplete.
• We may deny the request in circumstances permitted by law. If we deny it, we will provide a written explanation and describe any additional rights you may have.

Request Confidential Communications

You may ask us to contact you in a specific way or at a different address. We will accommodate reasonable requests and will not require you to explain why.

Ask Us to Limit What We Use or Share

• You may ask us not to use or share certain health information for treatment, payment, health care operations, or with people involved in your care. We are generally not required to agree, but we will honor an agreed restriction except as permitted by law.
• If you pay in full out of pocket for a specific item or service, you may ask us not to disclose information about it to your health plan for payment or health care operations. We will agree unless the disclosure is required by law.

Get a List of Certain Disclosures

You may request an accounting of certain disclosures made during the six years before your request. The accounting will not include every disclosure, including many disclosures for treatment, payment, health care operations, or disclosures you authorized.

Get a Copy of This Notice

You may obtain a paper copy at any time, even if you agreed to receive the notice electronically.

Choose Someone to Act for You

A person with legal authority to act as your personal representative may exercise your rights, subject to applicable law. Different rules may apply to parents, guardians, unemancipated minors, and services a minor may consent to receive.

File a Complaint Without Retaliation

You may complain to us or to the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you or deny care because you filed a complaint or exercised a privacy right.

Your Choices

Family, Friends, and Others Involved in Your Care

You may tell us whether we may share information with family, close friends, caregivers, or others involved in your care or payment for your care. If you cannot tell us your preference, we may share relevant information when we determine it is in your best interest and is permitted by law.

Disaster Relief

We may share limited information with an authorized disaster-relief organization to help notify family or others about your location, condition, or death, unless you object when you have the opportunity.

Uses and Disclosures Requiring Written Authorization

• We will obtain your written authorization for most uses and disclosures of psychotherapy notes, marketing when authorization is required, and a sale of protected health information, unless a legal exception applies.
• Other uses and disclosures not described in this notice will be made only with your written authorization unless permitted or required by law.
• You may revoke an authorization in writing at any time, except to the extent we have already relied on it or another legal exception applies.

How We May Use and Share Your Health Information

Each use or disclosure is subject to applicable legal conditions, the minimum-necessary standard when it applies, and any more protective federal or state law.

Treat You and Coordinate Care

We may use and share information with health professionals and organizations involved in your treatment or care coordination.

Run the Practice and Improve Care

We may use and share information for quality improvement, patient safety, case management, training, credentialing, audits, compliance, legal services, business planning, customer service, and practice management.

Bill and Obtain Payment for Services

We may use and share information to obtain payment, determine eligibility or benefits, obtain prior authorization, coordinate benefits, and manage claims or appeals.

Contact You About Care and Services

We may contact you for appointment reminders, registration, care coordination, prescription or laboratory follow-up, treatment alternatives, health-related benefits or services, patient satisfaction, and other communications related to your care or our operations.

Work With Business Associates

We may share information with companies that perform services for us. They must appropriately safeguard the information and may use it only as allowed by law and their agreements with us.

Public Health and Safety Activities

We may disclose information for authorized public health activities, reports of suspected abuse or neglect, product safety, and to prevent or lessen a serious and imminent threat when permitted by law.

Health Oversight and Government Functions

We may disclose information for authorized oversight, licensure, accreditation, audits, military or veterans activities, national security, protective services, correctional institutions, and other specialized government functions permitted by law.

Comply With Law, Workers' Compensation, and Legal Process

We may disclose information when law requires it, for authorized workers' compensation purposes, and in response to qualifying court orders, subpoenas, law-enforcement requests, or other lawful process when legal requirements are met.

Research

We may use or share information for approved or otherwise legally permitted health research.

Decedents and Organ Donation

We may disclose information to coroners, medical examiners, funeral directors, and organ or tissue procurement organizations as permitted by law.

Specially Protected Health Information

When another federal or state law is more protective than HIPAA, we will follow the more protective law and obtain any additional consent or authorization it requires.

Substance Use Disorder Records Protected by 42 CFR Part 2

To the extent we create, receive, or maintain substance use disorder patient records protected by 42 CFR part 2, we will not use or disclose those records, or testimony describing their contents, in a civil, criminal, administrative, or legislative investigation or proceeding against you unless permitted by your written consent or by a qualifying court order and required legal process. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure.

Other Information Subject to Greater Protection

Depending on applicable law and services, additional protections may apply to mental or behavioral health information, psychotherapy records, HIV/AIDS and sexually transmitted infection information, genetic testing, reproductive or sexual health information, communicable disease information, services provided to minors with independent consent rights, and other specially protected records. Any applicable state-specific addendum is incorporated into this notice. A copy is available at [STATE ADDENDUM LINK] or from our Privacy Official.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information, provide this notice, and follow the notice currently in effect.
• We will notify affected individuals following a breach of unsecured protected health information when required by law.
• We will use reasonable safeguards and limit access to people and organizations who need information for permitted purposes.
• We will not use or disclose your information inconsistently with this notice unless you authorize us in writing or the use or disclosure is otherwise permitted or required by law.

Changes to This Notice

We may change this notice and make the revised notice apply to all protected health information we maintain. The current notice will be available on our website, at our care locations, through the patient portal when available, and upon request.

Questions, Requests, and Complaints

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.

Availability and Acknowledgment

This notice is available electronically and in paper form upon request. We may ask you to acknowledge receipt. Acknowledgment confirms receipt only; it is not an authorization for additional uses or disclosures, and refusing to acknowledge receipt will not prevent care.

Entities and Locations Covered by This Notice

[LIST OR DESCRIBE THE LEGAL ENTITY, AFFILIATED COVERED ENTITIES, ORGANIZED HEALTH CARE ARRANGEMENT PARTICIPANTS, AND SERVICE LOCATIONS COVERED BY THIS NOTICE.]