Effective Date: September 24, 2018
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.
When it comes to your health information, you have certain rights. This section explains your rights and some of my responsibilities to help you.
- You can ask to see or get an electronic or paper copy of your medical record and other health information I have about you.
- I will provide a copy or a summary of your health information, usually within 30 days of your request. I may charge a reasonable, cost-based fee.
- You can ask me to correct health information about you that you think is incorrect or incomplete. I may say “no” to your request, but we’ll tell you why in writing within 60 days.
- You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address. I will say “yes” to all reasonable requests.
- You can ask me not to use or share certain health information for treatment, payment, or our operations. I am not required to agree to your request, and I may say “no” if it would affect your care.
- You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why.
- I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked me to make). I’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.
- You can ask for a paper copy of this notice at any time, and I will provide you with a paper copy promptly.
- 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. I will make sure the person has this authority and can act for you before taking any action.
- You can complain if you feel I have violated your rights. 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 hhs.gov/ocr/privacy/hipaa/complaints/. I will not retaliate against you for filing a complaint.
For certain health information, you can tell me your choices about what I share. You have both the right and choice to tell me to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.
How do I typically use or share your health information?
I typically use or share your health information in the following ways.
Treat you. I can use your health information and share it with other professionals who are treating you. For example, I routinely provide a written summary to your child’s pediatrician.
Bill for your services. I can use and share your health information to bill and get payment from health plans or other entities.
How else can I use or share your health information?
I am allowed or in some cases, required, to share your information in other ways. I have to meet many conditions in the law before I can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
I can share health information about you for certain situations such as:
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
Comply with the law
I will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that I am complying with federal privacy law. For example,
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
- I can share health information about you in response to a court or administrative order, or in response to a subpoena.
- I am required by law to maintain the privacy and security of your protected health information.
- I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- I must follow the duties and privacy practices described in this notice and give you a copy of it.
- I will not use or share your information other than as described here unless you tell us we can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
The terms of this notice are subject to change, and the changes will apply to all information I have about you. The new notice will be available upon request and on my web site.
As as one-person company, I am the Privacy Officer as well as the practitioner. You can reach me, Christina Sainato, at firstname.lastname@example.org or 626-657-7360 for more information.