Protected health information (PHI), about you. is maintained as a written and/or electronic
record of your contacts or visits for healthcare services with our practice. Specifically, PHI
is information about you, including demographic information (i.e., name, address, phone. etc.).
that may identify you and relates to your post, present or future physical or mental health
condition and related healthcare services.
Our practice is legally required to maintain the confidentiality of your PHI, and to follow
specific rules when using or disclosing this information. This Notice describes your rights to
access and control your PHI. It also describes how we follow applicable rules when using or
disclosing your PHI to provide your treatment, obtain payment for services you receive, manage
our healthcare operations and for other purposes that are permitted or required by law.
Your Rights Under The Privacy Rule
Following is a statement of your rights, under the Privacy Rule, in reference to your PHI.
Please feel free to discuss any questions with our staff.
You have the right to receive, and we are required to provide you with, a copy of this
Notice of Privacy Practices
- We are required by law to follow the terms of this Notice. We reserve the right to change the
terms of the Notice, and to make the new Notice provisions effective for all PHI that we
maintain. We will provide you with a copy of our current Notice if you call our office and
request that a copy be sent to you in the mail, or ask for one at the time of your next
appointment. The Notice will also be posted in a conspicuous location in the practice, and if
such is maintained, on the practice's web site.
You have the right to authorize other use and disclosure - This means we will
only use or disclose your PHI as described in this notice, unless you authorize other use or
disclosure in writing. For example, we would need your written authorization to use or disclose
your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we
intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to
the extent that your healthcare provider, or our practice has taken an action in reliance on the
use or disclosure indicated in the authorization.
You have the right to request an alternative means of confidential communication
- This means you have the right to ask us to contact you about medical matters using an
alternative method (i.e., email, fax, telephone), and/or to a destination (i.e., cell phone
number, alternative address, etc.) designated by you. You must inform us in writing, using a
form provided by our practice, how you wish to be contacted if other than the address/phone
number that we have on file. We will follow all reasonable requests.
You have the right to inspect and obtain a copy your PHI* - This means you may
submit a written request to inspect or obtain a copy of your complete health record, or to
direct us to disclose your PHI to a third party. If your health record is maintained
electronically, you will also have the right to request a copy in electronic format. We have the
right to charge a reasonable, cost-based fee for paper or electronic copies as established by
federal guidelines. We are required to provide you with access to your records within 30 days of
your written request unless an extension is necessary. In such cases, we will notify you of the
reason for the delay, and the expected date when the request will be fulfilled.
You have the right to request a restriction of your PHI* - This means you may
ask us, in writing, not to use or disclose any part of your protected health information for the
purposes of treatment, payment or healthcare operations. If we agree to the requested
restriction, we will abide by it, except in emergency circumstances when the information is
needed for your treatment. In certain cases, we may deny your request for a restriction. You
will have the right to request. in writing, that we restrict communication to your health plan
regarding a specific treatment or service that you, or someone on your behalf, has paid for in
full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.
You have the right to request an amendment to your protected health information* - This means you may submit a written request to amend your PHI for as long as we maintain this
information. In certain cases, we may deny your request.
You have the right to request a disclosure accountability* - You may submit a
written request for a listing of disclosures we have made of your PHI to entities or persons
outside of our practice except for those made upon your request, or for purposes of treatment,
payment or healthcare operations. We will not charge a fee for the first accounting provided in
a 12-month period.
You have the right to receive a privacy breach notice - You have the right to
receive written notification if the practice discovers a breach of your unsecured PHI. and
determines through a risk assessment that notification is required.
How We May Use or Disclose Protected Health Information
Following are examples of uses and disclosures of your protected health information that we are
permitted to make. These examples are not meant to be exhaustive, but to describe possible types
of uses and disclosures.
Treatment - We may use and disclose your PHI to provide, coordinate. or manage your healthcare
and any related services. This includes the coordination or management of your healthcare with a
third party that is involved in your care and treatment. For example, we would disclose your
PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI
to other Healthcare Providers who may be involved in your care and treatment.
Payment - Your PHI will be used, as needed, to obtain payment for your healthcare services. This
may include certain activities that your health insurance plan may undertake before it approves
or pays for the healthcare services we recommend for you such as, making a determination of
eligibility or coverage for insurance benefits.
Healthcare Operations - We may use or disclose, as needed, your PHI in order to support the
business activities of our practice. This includes, but is not limited to business planning and
development, quality assessment and improvement. medical review, legal services, auditing
functions and patient safety activities.
Special Notices - We may use or disclose your PHI, as necessary, to contact you to remind you of
your appointment. We may contact you by phone or other means to provide results from exams or
tests. to provide information that describes or recommends treatment alternatives regarding your
care, or to provide information about health-related benefits and services offered by our
We may contact you regarding fundraising activities, but you will have the right to opt out of
receiving further fundraising communications. Each fundraising notice will include instructions
for opting out.
Health Information Exchanges - We may participate in one or more health information exchanges or
other such organizations to facilitate the electronic exchange of information for the purposes
of treatment, payment, or healthcare operations between organizations and among the practice. If
you do not want your information shared through a health information exchange you may opt out by
contacting our office and completing a written opt out form that our office can provide to you.
Opting out will not preclude any organization that has already has received or accessed your
information from retaining such information. If you opt out, you can choose to resume
participation in the health information exchange by submitting a written request to one of our
To Others Involved in Your Healthcare - Unless you object, we may disclose to a member of your
family, a relative, a close friend or any other person that you identify, your PHI that directly
relates to that person's involvement in your healthcare. If you are unable to agree or object to
such a disclosure, we may disclose such information as necessary if we determine that it is in
your best interest based on our professional judgment. We may use or disclose PHI to notify or
assist in notifying a family member, personal representative or any other person that is
responsible for your care, of your general condition or death. If you are not present or able to
agree or object to the use or disclosure of PHI (e.g., in a disaster relief situation), then
your healthcare provider may, using professional judgment, determine whether the disclosure is
in your best interest. In this case, only the PHI that is necessary will be disclosed.
Other Permitted and Required Uses and Disclosures - We are also permitted to use or disclose
your PHI without your written authorization, or providing you an opportunity to object. for the
following purposes: if required by state or federal law; for public health activities and safety
issues (e.g. a product recall); for health oversight activities; in cases of abuse. neglect, or
domestic violence; to avert a serious threat to health or safety; for research purposes; in
response to a court or administrative order, and subpoenas that meet certain requirements; to a
coroner, medical examiner or funeral director; to respond to organ and tissue donation requests;
to address worker's compensation, law enforcement and certain other government requests, and for
specialized government functions (e.g., military, national security, etc); with respect to a
group health plan, to disclose information to the health plan sponsor for plan administration;
and if requested by the Department of Health and Human Services in order to investigate or
determine our compliance with the requirements of the Privacy Rule.
You have the right to complain to us, or directly to the Secretary of the Department of Health
and Human Services if you believe your privacy rights have been violated by us. We will not
retaliate against you for filing a complaint.
You may ask questions about your privacy rights. file a complaint or submit a written request
(for access, restriction, or amendment of your PHI or to obtain a disclosure accountability) by
notifying our Privacy Manager at:
Nan Irwin (614) 485-2665
* If you have questions regarding your privacy rights, or would like to submit any type of
written request described above. please feel free to contact our Privacy Manager. Contact
information is provided at the bottom of the following page.