Notice of Privacy Practices

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.

Our Company is required by law to maintain the privacy of protected health information and to provide you adequate notice of your rights and our legal duties and privacy practices with respect to the uses and disclosures of protected health information. [45 CFR § 164.520] We will use or disclose protected health information in a manner that is consistent with this notice.

Our Company maintains a record (paper/electronic file) of the information we receive and collect about you and of the care we provide to you. This record includes physicians’ orders, assessments, medication lists, clinical progress notes and billing information.

As required by law, our Company maintains policies and procedures about our work practices, including how we provide and coordinate care provided to our patients. These policies and procedures include how we create, maintain and protect medical records; access to medical records and information about our patients; how we maintain the confidentiality of all information related to our patients; security of the building and electronic files and how we educate staff on privacy of patient information.

As our patient, information about you must be used and disclosed to other parties for purposes of treatment, payment and health care operations. Examples of information that must be disclosed:

  • Treatment: Providing, coordinating or managing health care and related services, consultation between health care providers relating to a patient or referral of a patient for health care from one provider to
    another. For example, we meet on a regular basis to discuss how to coordinate care to patients and schedule visits after treatment.
  • Payment: Billing and collecting for services provided, determining plan eligibility and coverage, utilization review (UR), precertification, medical necessity review. For example, occasionally the insurance company requests a copy of the medical record be sent to them for review prior to paying the bill.
  • Health Care Operations: General administrative and business functions, quality assurance/improvement activities; medical review; auditing functions; developing clinical guidelines; determining the competence or qualifications of health care professionals; evaluating our performance; conducting training programs with students or new employees; licensing, survey, certification, accreditation and credentialing activities; internal auditing and certain fundraising and marketing activities. For example, our Company periodically holds clinical record review meetings where the consulting professional of our record review committee will audit clinical records for meeting professional standards and utilization review.


The following uses and disclosures do not require your consent, and include, but are not limited to, a release of information contained in financial records and/or medical records, including information concerning communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), drug/alcohol abuse, psychiatric diagnosis and treatment records and/or laboratory test results, medical history, treatment progress and/or any other related information to:

  1. Your insurance company, self-funded or third-party health plan, Medicare, Medicaid or any other person or entity that may be responsible for paying or processing for payment any portion of your bill for services;
  2. Any person or entity affiliated with or representing us for purposes of administration, billing and quality and risk
  3. Any hospital, nursing home or other health care facility to which you may be admitted;
  4. Any assisted living or personal care facility of which you are a resident;
  5. Any physician providing you care;
  6. Licensing and accrediting bodies;
  7. Contact you to provide appointment reminders or information about other health activities we provide;
  8. Other health care providers to initiate treatment.


We are permitted to use or disclose information about you without consent or authorization in the following circumstances:

  1. In emergency treatment situations, if we attempt to obtain consent as soon as practicable after treatment;
  2. Where substantial barriers to communicating with you exist and we determine that the consent is clearly inferred
    from the circumstances;
  3. Where we are required by law to provide treatment and we are unable to obtain consent;
  4. Where the use or disclosure of medical information about you is required by federal, state or local law;
  5. To provide information to state or federal public health authorities, as required by law to: prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify persons of recalls of products they may be using; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence (if you agree or when required or authorized by law);
  6. Health care oversight activities such as audits, investigations, inspections and licensure by a government health oversight agency as authorized by law to monitor the health care system, government programs and compliance with civil rights laws;
  7. Certain judicial administrative proceedings you are involved in a lawsuit or a dispute. We may disclose medical information about your response to a court or administrative order, a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested;
  8. Certain law enforcement purposes such as helping to identify or locate a suspect, fugitive, material witness or missing person, or to comply with a court order or subpoena and other law enforcement purposes;
  9. To coroners, medical examiners and funeral directors, in certain circumstances, for example, to identify a deceased person, determine the cause of death or to assist in carrying out their duties;
  10. For cadaver organ, eye or tissue donation purposes to communicate to organizations involved in procuring, banking or transplanting organs and tissues (if you are an organ donor);
  11. For certain research purposes, under very select circumstances, we may use your health information for research. Before we disclose any of your health information for such research purposes, the project will be subject to an extensive approval process. We will usually request your written authorization before granting access to your individually identifiable health information;
  12. To avert a serious threat to health and safety: To prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public, such as when a person admits to participation in a violent crime or serious harm to a victim or is an escaped convict. Any disclosure, however, would only be to someone able to help prevent the threat;
  13. For specialized government functions, including military and veterans’ activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institution and custodial situations; and
  14. For Workers’ Compensation purposes: Workers’ compensation or similar programs provide benefits for work-related injuries or illness.


We are permitted to use or disclose information about you without consent or authorization provided you are informed in advance and given the opportunity to agree to or prohibit or restrict the disclosure in the following circumstances:

  1. Use of a directory (includes name, location, condition described in general terms) of individuals served by our Company; and
  2. To a family member, relative, friend, or other identified person, the information relevant to such person’s involvement in your care or payment for care; to notify family member, relative, friend, or other identified person of the individual’s location, general condition or death.


Other uses and disclosures will be made only with your written authorization. That authorization may be revoked, in writing, at any time, except in limited situations.

  • Request restrictions on uses and disclosures of your protected health information for treatment payment or health care operations. However, we are not required to agree to any requested restriction. Restrictions to which we agree will be documented. Agreements for further restrictions may, however, be terminated under applicable circumstances (e.g., emergency treatment).
  • Confidential communication of protected health information. We will arrange for you to receive protected health information by reason able alternative means or at alternative locations. Your request must be in writing. We do not require an explanation for the request as a condition of providing communications on a confidential basis and will attempt to honor reasonable requests for confidential communications.
  • Inspect and obtain copies of protected health information which is maintained in a designated record set, except for psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding, or protected health information that is subject to the Clinical Laboratory Improvements Amendments of 1988 [42 USC§ 263a and 45 CFR 493 § (a)(2)]. If you request a copy of your health information, we will charge a reasonable fee for copying in accordance with applicable state and federal regulations.
  • If we deny access to protected health information, you will receive a timely, written denial in plain language that explains the basis for the denial, your review rights and an explanation of how to exercise those rights. If we do not maintain the medical record, we will tell you where to request the protected health information.
  • Request to amend protected health information for as long as the protected health information is maintained in the designated record set. A request to amend your record must be in writing and must include a reason to support the requested amendment. We will act on your request within sixty (60) days of receipt of the request.
  • We may extend the time for such action by up to 30 days, if we provide you with a written explanation of the reasons for the delay and the date by which we will complete action on the request.