HIPAA Notice of Privacy Practices

Effective Date: 1/25/2025

This Notice describes how your medical information may be used and disclosed and how you can access this information. Please review it carefully.

Your Rights

You have certain rights when it comes to your health information. This section explains your rights and some of my responsibilities to help you:

  • Get a copy of your medical records: You can ask to see or receive an electronic or paper copy of your health records. I will provide a copy or summary, usually within 30 days of your request. Fees may apply.

  • Request corrections: You can ask me to correct your health information if you believe it is incorrect or incomplete. I may deny your request, but I’ll explain why in writing within 60 days.

  • Request confidential communications: You can ask me to contact you in a specific way (e.g., home or office phone) or to send mail to a different address.

  • Ask me to limit what I use or share: You can ask me not to use or share certain health information for treatment, payment, or operations. I’ll consider your request, though I am not required to agree.

  • Get a list of disclosures: You can ask for a list of times I’ve shared your health information for six years prior to the request date, including who I shared it with and why.

  • Choose someone to act for you: If you have a medical power of attorney or are a legal guardian, you can exercise your rights on behalf of another.

  • File a complaint if your rights are violated: You can file a complaint with me or with the U.S. Department of Health and Human Services. I will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can make choices about what I share. This mainly applies to:

  • Sharing information with your family, close friends, or others involved in your care.

  • Sharing information in disaster relief situations.

  • Including your information in a hospital directory.

If you are unable to express your preference (e.g., unconscious), I may 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.

My Uses and Disclosures

I typically use or share your health information in the following ways:

  1. Treatment: I can use your health information to treat you and share it with other professionals involved in your care.

    • Example: A doctor treating you for an injury asks another doctor about your overall health condition.

  2. Operations: I can use and share your health information to improve the quality of care, train staff, and ensure compliance with healthcare standards.

    • Example: I use health information about you to manage your treatment and services.

  3. Billing and Payment: I can use and share your health information to bill and get payment from health plans or other entities.

    • Example: I provide details about your care to your health insurance plan for reimbursement.

Other ways I may use or share your information include:

  • Public health and safety efforts.

  • Responding to lawsuits or legal actions.

  • Complying with law enforcement or government requests.

  • Addressing workers’ compensation, law enforcement, and other government requests.

My Responsibilities

  • I am required by law to maintain the privacy and security of your protected health information.

  • I will notify you promptly if a breach occurs that may have compromised your information.

  • I will not use or share your information except as described here unless you provide written authorization.

Changes to This Notice

I reserve the right to change this Notice and the privacy practices described here. Updates will apply to all information I have about you, and the new Notice will be made available upon request, in my office, and on my website.

Contact Information

If you have questions, concerns, or want to file a complaint, please contact me:

[Your Name or Practice Name]
[Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

I value your privacy and am committed to protecting your health information.