The Entity is required to:

• Maintain the privacy of your health information;
• Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you; and abide by the terms of this notice.
• The Entity reserves the right to change the terms of the notice of privacy practices and make the new notice provisions effective for all protected health information that it maintains. The Entity also reserves the right change the terms of its notice with respect to any applicable more limited uses and disclosures.
• The Entity will promptly revise and distribute its notice whenever The Entity makes a substantial change to any of its privacy practices.
• The Entity will not use or disclose your health information without your authorization, except as described in this notice.

Your Health Information Rights - You have a right to:

Request a restriction on certain uses and disclosures of your health information.

You have the right to request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or The Entity's payment or health care operation activities. However, The Entity is not required to agree to your requested restriction. For example, if you are an employee of the clinic and you receive health care services in the clinic, you may request that your health care record not be maintained in the general record filing area.

Receive Confidential Communications.

You have the right to request that The Entity communicate your health information to you by alternative means or at alternative locations. The Entity shall accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your health care record.

Inspect and obtain a copy of your health record.

You have the right to inspect and obtain a copy of your health care record. This request for access to your health care record must be in submitted in writing to The Entity. This right may not apply to certain types of psychotherapy notes and The Entity may charge you a reasonable fee for a copy of your health care record. For example, you may request a copy of your health care record from your family physician.

Amend your health record.

You have the right to request an amendment to your health care record if you believe your health information is incorrect or incomplete. You may be asked to make this request in writing and state the reason why your health record should be changed. If The Entity did not create the health information you believe is incorrect or if The Entity disagrees with you, The Entity may deny your request. For example, if you believe that information in your medical history is incorrect, such as your birth date, you may request that this information be amended.

Obtain an accounting of disclosures of your health information.

You have the right to an accounting of disclosures of your health information that The Entity has made in compliance with state and federal law. The accounting will describe the dates of each disclosure, a brief description of information disclosed and the reason for disclosure. You will receive one accounting per year at no charge and The Entity may charge you a reasonable fee for each subsequent request. For example, you may request an accounting of disclosures made from your health record in the last year to the State for disease reporting.

Obtain a paper copy of the notice upon request.

You have the right to obtain a paper copy of the notice upon request. For example, if you received the notice electronically, you may request that The Entity provide a paper copy of the notice.

Uses and Disclosures for Treatment, Payment and Health Care Operations

The Entity is permitted by the federal privacy rule to use or disclose your protected health information for treatment, payment or health care operations.

The Entity may use or disclose your health information for treatment.

The Entity may use or disclose your health information in the provision, coordination or management of your health care.

• Example: Your information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment.
• Example: The Entity may use your health information to provide you with an appointment reminder.
• Example: The Entity may send you information about treatment alternatives or other health related services that may be of interest to you.

The Entity may use or disclose your health information for payment.

The Entity may use or disclose your health information to obtain reimbursement for the provision of health care services. The bill may include information that identifies you, your diagnosis and your treatment.

• Example: The Entity may use or disclose your information to your insurer to obtain payment for the provision of health care services.

The Entity may use or disclose your health information for routine health care operations.

The Entity may use or disclose your health information for evaluation of patient care services, evaluating the performance of health care providers, activities relating to compliance with the law and business planning and development.

• Example: The Entity may review your health record to determine the efficiency of the services provided to you in the emergency room.
• Example: The Entity may contact you as part of a fundraising activity sponsored by your health care provider.

Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization

Without your written authorization, The Entity may use or disclose your health information for the following purposes:

As Required by Law: The Entity may use or disclose protected health information to the extent that the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law. Uses or disclosures required by federal privacy rule and limited by the more protective requirements of state law include the following:

• Disclosures about victims of elderly or child abuse;
• Disclosures for judicial and administrative proceedings; or
• Disclosures for law enforcement purposes.