Your Information |
Your Rights |
Our Responsibilities
The use of the words “your” or “you” shall refer to both the Responsible Party and the Participant.
This notice describes how medical information, often referred to as “Personal Health Information” (“PHI”), about you may be used and disclosed and how you can get access to this information.
Your Rights
You have the right to
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
01
/
07
Choose someone to act for you.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
02
/
07
Get a copy of this privacy notice.
Your medical power of attorney or legal guardian can exercise your rights and make choices about your health information. We'll verify their authority before taking any action on your behalf.
03
/
07
Request confidential communication.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.
04
/
07
Ask us to limit the information we share
You can request limitations on how we use or share your health information, but we may decline if it affects your care. If you pay for a service out-of-pocket, you can ask us not to share that information with your health insurer. We'll agree unless legally required to share it.
05
/
07
Ask us to correct your medical record
You can request corrections to your health information if you believe it's incorrect or incomplete. We'll respond within 60 days, explaining in writing if we decline your request.
06
/
07
Get a copy of your paper or electronic medical record
You can request to view or receive a copy of your medical record and other health information we have about you. We'll provide this within 30 days of your request, possibly charging a reasonable fee.
07
/
07
File a complaint if you believe your privacy rights have been violated
If you feel we've violated your rights, you can file a complaint with us directly or with the U.S. Department of Health and Human Services Office for Civil Rights. For the latter, send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1-877-696-6775, or visit
www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
Our Uses and Disclosures
You have the right to
1. Treat You
01
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08
Treat you.
We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
1. Treat You
01
/
08
Treat you.
We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
1. Treat You
01
/
08
Treat you.
We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
1. Treat You
01
/
08
Treat you.
We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
2. Run Our Organization
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08
Run our organization.
We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
2. Run Our Organization
02
/
08
Run our organization.
We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
2. Run Our Organization
02
/
08
Run our organization.
We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
2. Run Our Organization
02
/
08
Run our organization.
We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
3. Comply with The Law
03
/
08
Comply with the law.
We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
3. Comply with The Law
03
/
08
Comply with the law.
We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
3. Comply with The Law
03
/
08
Comply with the law.
We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
3. Comply with The Law
03
/
08
Comply with the law.
We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
4. Bill for Your Services
04
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08
Bill for your services.
We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
4. Bill for Your Services
04
/
08
Bill for your services.
We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
4. Bill for Your Services
04
/
08
Bill for your services.
We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
4. Bill for Your Services
04
/
08
Bill for your services.
We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
05. Respond to Lawsuits
05
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08
Respond to lawsuits and legal actions.
Example: We can share health information about you in response to a court or administrative order, or in response to a subpoena. We can share health information about you pursuant to your permission and release.
05. Respond to Lawsuits
05
/
08
Respond to lawsuits and legal actions.
Example: We can share health information about you in response to a court or administrative order, or in response to a subpoena. We can share health information about you pursuant to your permission and release.
05. Respond to Lawsuits
05
/
08
Respond to lawsuits and legal actions.
Example: We can share health information about you in response to a court or administrative order, or in response to a subpoena. We can share health information about you pursuant to your permission and release.
05. Respond to Lawsuits
05
/
08
Respond to lawsuits and legal actions.
Example: We can share health information about you in response to a court or administrative order, or in response to a subpoena. We can share health information about you pursuant to your permission and release.
06. Answer any Info Requests
06
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08
Fulfill any of your information requests.
This can include, but may not be limited to, all of the information requests found within our Privacy Practices. Example: We use your information to deliver you a copy of your records
06. Answer any Info Requests
06
/
08
Fulfill any of your information requests.
This can include, but may not be limited to, all of the information requests found within our Privacy Practices. Example: We use your information to deliver you a copy of your records
06. Answer any Info...
06
/
08
Fulfill any of your information requests.
This can include, but may not be limited to, all of the information requests found within our Privacy Practices. Example: We use your information to deliver you a copy of your records
06. Answer any Info Requests
06
/
08
Fulfill any of your information requests.
This can include, but may not be limited to, all of the information requests found within our Privacy Practices. Example: We use your information to deliver you a copy of your records
07. Handle Donation Requests
07
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08
Respond to organ and tissue donation requests.
Example: We can share health information about you with organ procurement organizations.
07. Handle Donation Requests
07
/
08
Respond to organ and tissue donation requests.
Example: We can share health information about you with organ procurement organizations.
07. Handle Donation Re...
07
/
08
Respond to organ and tissue donation requests.
Example: We can share health information about you with organ procurement organizations.
07. Handle Donation Requests
07
/
08
Respond to organ and tissue donation requests.
Example: We can share health information about you with organ procurement organizations.
08. Coordinate with Examiners
08
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08
Work with a medical examiner or funeral director.
Example: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
08. Coordinate with Examiners
08
/
08
Work with a medical examiner or funeral director.
Example: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
08. Coordinate with ...
08
/
08
Work with a medical examiner or funeral director.
Example: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
08. Coordinate with Examiners
08
/
08
Work with a medical examiner or funeral director.
Example: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Our Responsibilities
01
We are required by law to maintain the privacy and security of your protected health information.
02
We must follow the duties and privacy practices described in this notice and give you a copy of it.
03
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
04
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
FOR MORE INFORMATION
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Your Choices About Sharing Health Information
At Havenwood, we've created a unique environment where our staff can develop healthy, meaningful relationships with our clients. This relational model is at the heart of our approach, and it's what sets us apart in the field of youth treatment.
Here's what makes a career at Havenwood special:
Regarding fundraising
We may contact you for fundraising efforts, but you can opt out of future contacts
You have both the right and choice to tell us to
Share information in a disaster relief situation
Include your information in a hospital directory
Share information with your family, close friends, or others involved in your care
We never share your information without your written permission for
Marketing purposes
Sale of your information
Most sharing of psychotherapy notes
Special circumstances
If you're unable to communicate your preference (e.g., if unconscious), we may share your information if we believe it's in your best interest
We may share your information to lessen a serious and imminent threat to health or safety
Other Ways We May Share Your Information
We can share your health information in certain situations that contribute to public good, such as public health and research. These situations may include:
01
Preventing disease
02
Helping with product recalls
03
Reporting adverse reactions to medications
04
Reporting suspected abuse, neglect, or domestic violence
05
Preventing or reducing serious threats to health or safety
Before sharing your information for these purposes, we must meet specific legal conditions.
FOR MORE DETAIL, PLEASE VISIT
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
Government and Legal Requests for Your Health Information
We can use or share your health information in response to:
01
Workers' compensation claims
02
Law enforcement purposes or requests from law enforcement officials
03
Health oversight agencies for legally authorized activities
04
Special government functions, including:
Military operations
National security matters
Presidential protective services
These disclosures are governed by specific legal requirements and are made only when necessary.
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.