Notice of Privacy Practices
Notice of Privacy Practices

Notice of Privacy Practices

Notice of Privacy Practices
This notice describes how health information about you may be used and disclosed and how you can
get access to this information. Please review it carefully. The privacy of your health information is
important to us.
Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of your health information.
We are also required to give you this Notice about our privacy practices, our legal duties, and your
rights concerning your health information. We must follow the privacy practices that are described in
this notice while it is in effect. This Notice takes effect March 28, 2003, and will remain in effect until
we replace it. We reserve the right to change our privacy practices and the terms of this notice at
any time, provided the changes are permitted by applicable law. We reserve the right to make the
changes in our privacy practices and the new terms of our Notice effective for all health information
that we maintain, including health information we created or received before we made the changes.
Before we make a significant change in our privacy practices, we will change this Notice and make
the new Notice available upon request. You may request a copy of our notice at any time. For more
information about our privacy practices, or for additional copies of this Notice, please contact us using
the information listed at the end of this Notice.
Uses and Disclosures of health information
We use and disclose health information about you for treatment, payment, and healthcare operations.
For example:
Treatment: We may use or disclose your health information to a physician or other healthcare
provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we
provide to you.
Healthcare Operations: We may use and disclose your health information in connection with
our healthcare operations. Healthcare operations include quality assessment and improvement
activities, reviewing the competence or qualifications of healthcare professionals, evaluating
practitioner and provider performance, conducting training programs, accreditation,
certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or
healthcare operations, you may give us written authorization to use your health information or
to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in
writing at any time. Your revocation will not affect any use or disclosures permitted by your
authorization while it was in effect. Unless you give us a written authorization, we cannot use
or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in
the Patient Rights section of this Notice. We may disclose your health information to a family
member, friend or other person to the extent necessary to help with your healthcare or with
payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify or assist in the
notification of (including identifying or locating) a family member, your personal representative
or another person responsible for your care, of your location, your general condition, or death.
If you are present, then prior to use or disclosure of your health information, we will provide you
with an opportunity to object to such uses or disclosures. In the event of your incapacity or
emergency circumstances, we will disclose health information based on a determination using
our professional judgment disclosing only health information that is directly relevant to the
person's involvement in your healthcare. We will also use our professional judgment and our
experience with common practice to make reasonable inferences of your best interest in
allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms
of health information.
Marketing Health-Related Services: We will not use your health information for marketing
communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do
so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we
reasonable believe that you are a possible victim of abuse, neglect, or domestic violence or the
possible victim of other crimes. We may disclose your health information to the extent
necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed
Forces personnel under certain circumstances. We may disclose to authorized federal officials
health information required for lawful intelligence, counterintelligence, and other national
security activities. We may disclose to correctional institution or law enforcement official having
lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with
appointment reminders (such as voicemail messages, postcards, or letters).
Patient Rights
Access: You have the right to look at or get copies of your health information, with limited exceptions.
You may request that we provide copies in a format other than photocopies. We will use the format
you request unless we cannot practicably do so. (You must make a request in writing to obtain access
to your health information. You may obtain a form to request access by using the contact information
listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as
copies and staff time. You may also request access by sending us a letter to the address at the end
of this Notice. If you request copies, we will charge you $1.00 for each page, $20.00 per hour (with a
minimum of $20.00) for staff time to locate and copy your health information, and postage if you want
the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for
providing your health information in that format. If you prefer, we will prepare a summary or an
explanation of your health information for a fee. Contact us using the information listed at the end of
this Notice for a full explanation of our fee structure.)
Disclosure Accounting: You have the right to receive a list of instances in which we or our business
associates disclosed your health information for purposes, other that treatment, payment, healthcare
operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you
request this accounting more than once in a 12-month period, we may charge you a reasonable, costbased
fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or
disclosure of your health information. We are not required to agree to these additional restrictions,
but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your
health information by alternative means or to alternative locations. {You must make your request in
writing.}Your request must specify the alternative means or location, and provide satisfactory
explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request
must be in writing, and it must explain why the information should be amended.) we may deny your
request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are
entitled to receive this Notice in written from.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please
contact us. Contact Officer: Mara Concordia. If you are concerned that we may have violated your
privacy rights, or you disagree with a decision we made about access to your health information or in
response to a request you made to amend or restrict the use or disclosure of your health information
or to have us communicate with you by alternative means or at alternative locations, you may
complain to us using the contact information listed at the end of this Notice. You also may submit a
written complaint to the US Department of Health and Human Services. We will provide you with the
address to file your complaint with the US Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you
choose to file a complaint with us or with the US Department of Health and Human Services.

Testimonial:


StarStarStarStarStar Very pleased with first visit with Bethany. Her... —    (Patient since 2003) 

Very pleased with first visit with Bethany. Her touch was right for me and I especially appreciated her slow, measured work. Need more face and head attention next time and will ask for it.

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