Notice of Privacy Practices

1. We use your medical records to provide treatment, bill for services, receive payments, and manage healthcare operations. These privacy practices protect your personal information and ensure proper handling. For example, we review treatment records to ensure appropriate care. Send bills electronically or by mail, and make appointment reminder calls.
2. Federal and state laws require us to report abuse, neglect, domestic violence, or threats to social services or protective agencies. We will inform you or your legal representative about such reports unless disclosure increases the risk of harm.
3. We limit disclosed information to the minimum necessary. You can request an account of uses or disclosures beyond those described in Sections 1 and 2.
4. You or your legal representative can request your medical records. Submit your request in writing, identify the authorized person, specify the information, and include the recipient’s name, address, purpose, and expiration date of the authorization. You may revoke the authorization in writing at any time. Psychotherapy notes are part of your medical records. We respond to disclosure requests within 30 days or 60 days if records are stored off-site.
5. You may also request corrections to your records.
6. We may deny a disclosure request if it endangers someone’s safety, references another person (other than a healthcare provider), or risks harm when shared with a legal representative. If denied, you can request a review. Another licensed provider, not involved in the initial decision, will conduct the review within 30 days.
7. You can ask us to restrict the uses and disclosures in Section 1. While we are not required to agree, we will honor any agreed restriction unless you or your legal representative revokes it. We may revoke restrictions too, but information collected under them remains restricted.
8. If you have privacy-related concerns, contact the Secretary of the Department of Health and Human Services at 200 Independence Avenue SW, Washington, DC, 20201. Filing a complaint will not result in retaliation against you or your representative. We may also revoke such restrictions but information gathered while required by law or in an emergency. We may also revoke such restrictions but information gathered while the restriction was in place will remain restricted by such an agreement.
9. If you wish to complain about privacy related issues you may contact the Secretary of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington DC, 20201. In any case there will not be any retaliation against you or your legal representative for filing a complaint.
10. Our privacy practices may change based on legal or operational requirements.

This notice describes how medical information about you may be used and disclosed and how you can get access to it. Please review our privacy practices carefully.

I HAVE READ AND UNDERSTOOD THIS PRIVACY NOTICE AND MY RIGHTS CONCERNING USE AND DISCLOSURE OF PROTECTED HEATLH CARE INFORMATION.