Notice Of Privacy Practices For Protected Health Information
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2NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Law requires the privacy of your health information be maintained and that you are provided this
notice of the legal duties and privacy practices with respect to your health information. Other than
the uses and disclosures we described below, your health information will not be sold or provided
to any outside marketing organization.
We must abide by the terms of this notice and we reserve the right to change the terms of this
privacy notice. If a change is made, it will apply for all of your health information in our files, and
you will be notified in writing.
HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
GET ACCESS TO THIS INFORMATION.
USES AND DISCLOSURES
Here are examples of use and disclosure of your health care information:
1. We may have to disclose your health information to another health care provider, or a
hospital, etc., if it is necessary to refer you to them for the diagnosis, assessment, or
treatment of your health condition.
2. We may have to disclose your session records and your billing records to another party
(i.e. your insurance company), if they are potentially responsible for the payment of your
services.
3. We may need to use any information in your file for quality control purposes or any other
administrative purposes to run this practice.
4. We may need to use your name, address, phone number, and your records to contact
you to provide appointment reminder calls, recall postcards, Welcome and Thank You
cards, information about alternative therapies, or other related information that may be of
interest to you. If you are not at home to receive an appointment reminder, a message
will be left on your answering machine.
YOUR RIGHT TO LIMIT USES OR DISCLOSURES
You have the right to request that we do not disclose your information to specific individuals,
companies, or organizations. Any restrictions should be requested in writing. We are not
required to honor these requests. If we agree with your restrictions, the restriction is binding on
us.
PERMITTED USES AND DISCLOSURES WITHOUT YOUR CONSENT OR AUTHORIZATION
Under federal law, we are also permitted or required to use or disclose your information without
your consent or authorization in the following circumstances:
1. We are providing services to you based on the orders (referral) of a health care provider.
2. We provide services to you in an emergency and are unable to obtain your consent after
attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional
judgment we believe that you intend for us to provide care.
REVOKING YOUR AUTHORIZATION
You may revoke your authorization to us at any time in writing. There are two circumstances
under which we will not be able to honor your revocation request:
1. If your information has been released prior to your request to revoke your authorization.
165.508(b)(5)(I)
2. If you were required to give your authorization as a condition of obtaining insurance, the
insurance company may have a right to your information if they decide to contest any of
your claims.
CONFIDENTIAL COMMUNICATION
We will attempt to accommodate any reasonable written request regarding your contact
information that has been provided by you.
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