HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION

ABOUT YOU

We may use and disclose your health information for different

purposes, including treatment, payment, and health care operations.

For each of these categories, we have provided a description and an

example. Some information, such as HIV-related information, genetic

information, alcohol and/or substance use disorder treatment records,

and mental health records may be entitled to special confidentiality

protections under applicable state or federal law. We will abide

by these special protections as they pertain to applicable cases

involving these types of records.

Treatment. We may use and disclose your health information

for your treatment. For example, we may disclose your health

information to a specialist providing treatment to you.

Payment. We may use and disclose your health information to

obtain reimbursement for the treatment and services you receive

from us or another entity involved with your care. Payment activities

include billing, collections, claims management, and determinations

of eligibility and coverage to obtain payment from you, an insurance

company, or another third party. For example, we may send claims

to your dental health plan containing certain health information.

Healthcare Operations. We may use and disclose your health

information in connection with our healthcare operations. For example,

healthcare operations include quality assessment and improvement

activities, conducting training programs, and licensing activities.

Individuals Involved in Your Care or Payment for Your Care.

We may disclose your health information to your family or friends or

any other individual identified by you when they participate in your

care or in the payment for your care. Additionally, we may disclose

information about you to a patient representative. If a person has

the authority by law to make health care decisions for you, we will

treat that patient representative the same way we would treat you

with respect to your health information.

Disaster Relief. We may use or disclose your health information

to assist in disaster relief efforts.

Required by Law. We may use or disclose your health information

when we are required to do so by law.

Public Health Activities. We may disclose your health information

for public health activities, including disclosures to:

• Prevent or control disease, injury or disability;
• Report child abuse or neglect;
• Report reactions to medications or problems with products or devices;
• Notify a person of a recall, repair, or replacement of products or devices;
• Notify a person who may have been exposed to a disease or condition; or
• Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

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 the

protected health information of an inmate or patient.

Secretary of HHS. We will disclose your health information to the

Secretary of the U.S. Department of Health and Human Services

when required to investigate or determine compliance with HIPAA.

Worker’s Compensation. We may disclose your PHI to the

extent authorized by and to the extent necessary to comply with

laws relating to worker’s compensation or other similar programs

established by law.

Law Enforcement. We may disclose your PHI for law enforcement

purposes as permitted by HIPAA, as required by law, or in response

to a subpoena or court order.

Health Oversight Activities. We may disclose your PHI to

an oversight agency for activities authorized by law. These

oversight activities include audits, investigations, inspections, and

credentialing, as necessary for licensure and for the government

to monitor the health care system, government programs, and

compliance with civil rights laws.

Judicial and Administrative Proceedings. If you are involved in a

lawsuit or a dispute, we may disclose your PHI in response to a court

or administrative order. We may also disclose health information

about you in response to a subpoena, discovery request, or other

lawful process instituted by someone else involved in the dispute,

but only if efforts have been made, either by the requesting party

or us, to tell you about the request or to obtain an order protecting

the information requested.

Research. We may disclose your PHI to researchers when their

research has been approved by an institutional review board

or privacy board that has reviewed the research proposal and

established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors. We

may release your PHI to a coroner or medical examiner. This

may be necessary, for example, to identify a deceased person or

determine the cause of death. We may also disclose PHI to funeral

directors consistent with applicable law to enable them to perform

their duties.



Fundraising. We may contact you to provide you with information

about our sponsored activities, including fundraising programs,

as permitted by applicable law. If you do not wish to receive

such information from us, you may opt out of receiving the

communications.

SUD Treatment Information. If we receive or maintain any

information about you from a substance use disorder treatment

program that is covered by 42 CFR Part 2 (a “Part 2 Program”) through

a general consent you provide to the Part 2 Program to use and disclose

the Part 2 Program record for purposes of treatment, payment or

health care operations, we may use and disclose your Part 2 Program

record for treatment, payment and health care operations purposes

as described in this Notice. If we receive or maintain your Part 2

Program record through specific consent you provide to us or another

third party, we will use and disclose your Part 2 Program record only

as expressly permitted by you in your consent as provided to us.

In no event will we use or disclose your Part 2 Program record, or

testimony that describes the information contained in your Part 2

Program record, in any civil, criminal, administrative, or legislative

proceedings by any Federal, State, or local authority, against you,

unless authorized by your consent or the order of a court after it

provides you notice of the court order.

OTHER USES AND DISCLOSURES OF PHI

Your authorization is required, with a few exceptions, for disclosure

of psychotherapy notes, use or disclosure of PHI for marketing, and

for the sale of PHI. We will also obtain your written authorization

before using or disclosing your PHI for purposes other than those

provided for in this Notice (or as otherwise permitted or required by

law). You may revoke an authorization in writing at any time. Upon

receipt of the written revocation, we will stop using or disclosing

your PHI, except to the extent that we have already acted in reliance

on the authorization.

YOUR HEALTH INFORMATION RIGHTS

Access. You have the right to look at or get copies of your health

information, with limited exceptions. You must make the request

in writing. You may obtain a form to request access by using the

contact information listed at the end of this Notice. You may also

request access by sending us a letter to the address at the end of

this Notice. If you request information that we maintain on paper,

we may provide photocopies. If you request information that we

maintain electronically, you have the right to an electronic copy.

We will use the form and format you request if readily producible.

We will charge you a reasonable cost-based fee for the cost of

supplies and labor of copying, and for postage if you want copies

mailed to you. Contact us using the information listed at the end

of this Notice for an explanation of our fee structure.

If you are denied a request for access, you have the right to have the

denial reviewed in accordance with the requirements of applicable law.

Disclosure Accounting. With the exception of certain disclosures,

you have the right to receive an accounting of disclosures of

your health information in accordance with applicable laws and

regulations. To request an accounting of disclosures of your

health information, you must submit your request in writing to the

Privacy Official. If you request this accounting more than once in a

12-month period, we may charge you a reasonable, cost-based fee

for responding to the additional requests.

Right to Request a Restriction. You have the right to request

additional restrictions on our use or disclosure of your PHI by

submitting a written request to the Privacy Official. Your written

request must include (1) what information you want to limit, (2)

whether you want to limit our use, disclosure or both, and (3) to

whom you want the limits to apply. We are not required to agree to

your request except in the case where the disclosure is to a health

plan for purposes of carrying out payment or health care operations,

and the information pertains solely to a health care item or service

for which you, or a person on your behalf (other than the health

plan), has paid our practice in full.

Alternative Communication. You have the right to request

that we communicate with you about your health information by

alternative means or at alternative locations. You must make your

request in writing. Your request must specify the alternative means

or location, and provide satisfactory explanation of how payments

will be handled under the alternative means or location you request.

We will accommodate all reasonable requests. However, if we

are unable to contact you using the ways or locations you have

requested, we may contact you using the information we have.

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. If we agree to your request,

we will amend your record(s) and notify you of such. If we deny

your request for an amendment, we will provide you with a written

explanation of why we denied it and explain your rights.

Right to Notification of a Breach. You will receive notifications

of breaches of your unsecured protected health information as

required by law.

Electronic Notice. You may receive a paper copy of this Notice

upon request, even if you have agreed to receive this Notice

electronically on our Web site or by electronic mail (e-mail).

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have

questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights,

or if 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 U.S. Department of Health and Human Services.

We will provide you with the address to file your complaint with the

U.S. 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 U.S. Department of Health and Human Services.