Notice Effective Date: December 1, 2016
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.
AND DISCLOSURES OF HEALTH INFORMATION
Treatment: We may use or
disclose your health information to a physician or other healthcare provider
providing treatment to you, or to family and friends you approve.
Payment: We may use and
disclose your health information to obtain payment for services we provide to
Operations: We may use and disclose your health
information for healthcare operations.
Healthcare operations include quality assessment and improvement
activities, reviewing the competence or qualification of healthcare
professionals, evaluating practitioner and provider performance, conducting
training programs, accreditation, certification, or licensing activities.
Reminders: We may use and disclose your health
information to provide you with a reminder that you have an appointment for
treatment at Devereux.
Activities: We may use and disclose your health
information in order to contact you for fundraising activities. If you do not want Devereux to contact you
for fundraising, you may opt out at any time by calling (800) 345-1292 from 9 a.m.
to 5:00 p.m. Eastern.
By Law: We may use and disclose your health
information when required to do so by federal, state or local law.
Health Or Safety: We may use and disclose your health
information when necessary to prevent a serious threat to your health and
safety or the health and safety of another person.
following uses and disclosures will be made only with an authorization from
Most uses and disclosures of psychotherapy notes, the use of protected
health information for marketing and research purposes, and the sale of
protected health information. If
authorization is given, it may later be revoked in writing.
You can ask to see or get an electronic or paper copy of your medical
record or other health information we have about you. Usually, this includes medical and billing
records, but does not include any psychotherapy notes. If you request copies, we may charge you a
reasonable fee to locate and copy your information, and postage if you want the
copies mailed to you.
Amendment: You have the
right to request that we amend your health information.
Request Restrictions: You can ask us
not to use or share certain health
information for treatment, payment, or our operations. We are not required to agree to your request
and we may say “no” if it would affect your care.
Confidential Communications: You can ask us to contact you in a specific
way. We will agree to all reasonable
Accounting: You can ask
for a list (accounting) of the times we’ve shared your health information for
six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except
for those about treatment, payment, and health care operations, and certain
other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free
but will charge you a reasonable, cost-based fee if you ask for another one
within 12 months.
Copy of this
Notice: You can ask for a paper copy of this notice
at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy
- We are required
by law to maintain the privacy and security of your protected health
- We will let you
know promptly if a breach occurs that may have compromised the privacy or
security of your information.
- We must follow
the duties and privacy practices described in this notice and give you a copy
- We will not use
or share your information other than as described here unless you tell us we
can in writing. If you tell us we can,
you may change your mind at any time.
Let us know in writing if you change your mind.
- We can change the
terms of this notice, and the changes will apply to all information we have
about you. The new notice will be
available upon request, in our office, and on our website.
- You can complain
if you feel we have violated your rights by contacting the Corporate Privacy
Officer at (610) 542-3084 or email@example.com.
- You can file a
complaint with the U.S. Department of Health and Human Services Office for
Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201, by calling
1-877-696-6775 or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not
retaliate against you for filing a complaint.
For more information
Questions about this
notice should be directed to the Corporate Privacy Officer at (610) 542-3084 or firstname.lastname@example.org.